{"meta":{"createdOn":"2026-10-08 14:59:38"},"locations":[{"id":"TDGM","name":"LifeSmiles Dental at Grant Park","latitude":49.8566222,"longitude":-97.1673507,"geo":[49.8566222,-97.1673507],"google_place_id":"ChIJE6ItTkh16lIRFK0CyE9Q1bE","line1":"1120 Grant Ave","line2":"","full_address":"1120 Grant Ave  Winnipeg Canada R3M 2A6","postal_code":"R3M 2A6","locality":"Winnipeg","province":"Manitoba","country":"Canada","phone":"(204) 452-0560","website_url":"\/site\/contact\/winnipeg-dentist-grant-park-mall","shop_url":"","schedule":{"monday":{"start":"07:00","end":"21:00"},"tuesday":{"start":"07:00","end":"21:00"},"wednesday":{"start":"07:00","end":"21:00"},"thursday":{"start":"07:00","end":"21:00"},"friday":{"start":"08:00","end":"16:00"},"saturday":{"start":"09:30","end":"16:00"},"sunday":{"start":"00:00","end":"00:00"}},"isOpen":true,"customFields":{"Link to Google Maps":"https:\/\/maps.app.goo.gl\/eEkzzkcC7GKgmp5R7","Location":"Grant Park Mall","Multi Location Main Image":"\/files\/home-main-grant-park-mall.jpg","Multi Location Featured Services":"<h2>Featured Dental Services<\/h2>\r\n<p class=\"leadin\">We offer comprehensive dental care for the whole family, from children\u2019s services and Invisalign to restorative treatments like dental implants and dentures.<\/p>\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/preventive-dental-hygiene-winnipeg\" class=\"cms-button-success\" title=\"Preventive Hygiene at LifeSmiles Dental\">Preventive Hygiene<\/a><\/li>\r\n<li><a href=\"\/site\/children-dental-services-winnipeg\" class=\"cms-button-success\" title=\"Children's Dental Services at LifeSmiles Dental\">Children's Dental Services<\/a><\/li>\r\n<li><a href=\"\/site\/dental-implants-winnipeg\" class=\"cms-button-success\" title=\"Dental Implants at LifeSmiles Dental\">Dental Implants<\/a><\/li>\r\n<li><a href=\"\/site\/invisalign-clear-aligners-winnipeg\" class=\"cms-button-success\" title=\"Invisalign at LifeSmiles Dental\">Invisalign<\/a><\/li>\r\n<li><a href=\"\/site\/teeth-whitening-winnipeg\" class=\"cms-button-success\" title=\"Teeth Whitening at LifeSmiles Dental\">Teeth Whitening<\/a><\/li>\r\n<li><a href=\"\/site\/oral-surgery-winnipeg\" class=\"cms-button-success\" title=\"Oral Surgery at LifeSmiles Dental\">Oral Surgery<\/a><\/li>\r\n<\/ul>\r\n<details>\r\n<summary>View More Services<\/summary>\r\n<div class=\"details__content\">\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/extractions-wisdom-teeth-winnipeg\" class=\"cms-button-success\" title=\"Extractions &amp; Wisdom Tooth Removal at LifeSmiles Dental\">Extractions &amp; Wisdom Tooth Removal<\/a><\/li>\r\n<li><a href=\"\/site\/urgent-care-winnipeg\" class=\"cms-button-success\" title=\"Urgent Care at LifeSmiles Dental\">Urgent Care<\/a><\/li>\r\n<li><a href=\"\/site\/dental-sedation-winnipeg\" class=\"cms-button-success\" title=\"Dental Sedation at LifeSmiles Dental\">Dental Sedation<\/a><\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/details>","Multi Location Form Smartcode":"<div class="form-vertical">
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</script>","Practice Description":"","Practice NAP":"","Accepting New Patients":null}},{"id":"TCGM","name":"LifeSmiles Dental - La Salle","latitude":49.6911284,"longitude":-97.2655278,"geo":[49.6911284,-97.2655278],"google_place_id":"ChIJCV0vj3LnwVIRk-JgvD5boF8","line1":"49 Rue Principale","line2":"","full_address":"49 Rue Principale  La Salle Canada R0G 0A2","postal_code":"R0G 0A2","locality":"La Salle","province":"Manitoba","country":"Canada","phone":"(204) 736-8200","website_url":"\/site\/contact\/winnipeg-dentist-la-salle","shop_url":"","schedule":{"monday":{"start":"00:00","end":"00:00"},"tuesday":{"start":"09:00","end":"17:00"},"wednesday":{"start":"00:00","end":"00:00"},"thursday":{"start":"09:00","end":"17:00"},"friday":{"start":"09:00","end":"17:00"},"saturday":{"start":"00:00","end":"00:00"},"sunday":{"start":"00:00","end":"00:00"}},"isOpen":true,"customFields":{"Link to Google Maps":"https:\/\/maps.app.goo.gl\/JkJB1YTVzD64b7Di7","Location":"La Salle","Multi Location Main Image":"\/files\/home-main-la-salle.jpg","Multi Location Featured Services":"<h2>Featured Dental Services<\/h2>\r\n<p class=\"leadin\">We offer comprehensive dental care for the whole family, from children\u2019s services and Invisalign to restorative treatments like dental implants and dentures.<\/p>\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/preventive-dental-hygiene-winnipeg\" class=\"cms-button-success\" title=\"Preventive Hygiene at LifeSmiles Dental\">Preventive Hygiene<\/a><\/li>\r\n<li><a href=\"\/site\/children-dental-services-winnipeg\" class=\"cms-button-success\" title=\"Children's Dental Services at LifeSmiles Dental\">Children's Dental Services<\/a><\/li>\r\n<li><a href=\"\/site\/dental-implants-winnipeg\" class=\"cms-button-success\" title=\"Dental Implants at LifeSmiles Dental\">Dental Implants<\/a><\/li>\r\n<li><a href=\"\/site\/invisalign-clear-aligners-winnipeg\" class=\"cms-button-success\" title=\"Invisalign at LifeSmiles Dental\">Invisalign<\/a><\/li>\r\n<li><a href=\"\/site\/teeth-whitening-winnipeg\" class=\"cms-button-success\" title=\"Teeth Whitening at LifeSmiles Dental\">Teeth Whitening<\/a><\/li>\r\n<li><a href=\"\/site\/oral-surgery-winnipeg\" class=\"cms-button-success\" title=\"Oral Surgery at LifeSmiles Dental\">Oral Surgery<\/a><\/li>\r\n<\/ul>\r\n<details>\r\n<summary>View More Services<\/summary>\r\n<div class=\"details__content\">\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/extractions-wisdom-teeth-winnipeg\" class=\"cms-button-success\" title=\"Extractions &amp; Wisdom Tooth Removal at LifeSmiles Dental\">Extractions &amp; Wisdom Tooth Removal<\/a><\/li>\r\n<li><a href=\"\/site\/urgent-care-winnipeg\" class=\"cms-button-success\" title=\"Urgent Care at LifeSmiles Dental\">Urgent Care<\/a><\/li>\r\n<li><a href=\"\/site\/dental-sedation-winnipeg\" class=\"cms-button-success\" title=\"Dental Sedation at LifeSmiles Dental\">Dental Sedation<\/a><\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/details>","Multi Location Form Smartcode":"<div class="form-vertical">
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</script>","Practice Description":"","Practice NAP":"","Accepting New Patients":null}},{"id":"TEGM","name":"LifeSmiles Dental - Selkirk","latitude":50.1425223,"longitude":-96.8761832,"geo":[50.1425223,-96.8761832],"google_place_id":"ChIJEx5UisqK6lIRvWCk7jkyocg","line1":"343 Main St","line2":"","full_address":"343 Main St  Selkirk Canada R1A 1T3","postal_code":"R1A 1T3","locality":"Selkirk","province":"Manitoba","country":"Canada","phone":"(204) 482-3025","website_url":"\/site\/contact\/winnipeg-dentist-selkirk","shop_url":"","schedule":{"monday":{"start":"08:30","end":"16:00"},"tuesday":{"start":"08:30","end":"16:00"},"wednesday":{"start":"08:30","end":"16:00"},"thursday":{"start":"08:30","end":"16:00"},"friday":{"start":"08:30","end":"16:00"},"saturday":{"start":"00:00","end":"00:00"},"sunday":{"start":"00:00","end":"00:00"}},"isOpen":true,"customFields":{"Link to Google Maps":"https:\/\/maps.app.goo.gl\/R2DtBuLTY3mPKjfr8","Location":"Selkirk","Multi Location Main Image":"\/files\/home-main-selkirk.jpg","Multi Location Featured Services":"<h2>Featured Dental Services<\/h2>\r\n<p class=\"leadin\">We offer comprehensive dental care for the whole family, from children\u2019s services and Invisalign to restorative treatments like dental implants and dentures.<\/p>\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/preventive-dental-hygiene-winnipeg\" class=\"cms-button-success\" title=\"Preventive Hygiene at LifeSmiles Dental\">Preventive Hygiene<\/a><\/li>\r\n<li><a href=\"\/site\/children-dental-services-winnipeg\" class=\"cms-button-success\" title=\"Children's Dental Services at LifeSmiles Dental\">Children's Dental Services<\/a><\/li>\r\n<li><a href=\"\/site\/dental-implants-winnipeg\" class=\"cms-button-success\" title=\"Dental Implants at LifeSmiles Dental\">Dental Implants<\/a><\/li>\r\n<li><a href=\"\/site\/invisalign-clear-aligners-winnipeg\" class=\"cms-button-success\" title=\"Invisalign at LifeSmiles Dental\">Invisalign<\/a><\/li>\r\n<li><a href=\"\/site\/teeth-whitening-winnipeg\" class=\"cms-button-success\" title=\"Teeth Whitening at LifeSmiles Dental\">Teeth Whitening<\/a><\/li>\r\n<li><a href=\"\/site\/oral-surgery-winnipeg\" class=\"cms-button-success\" title=\"Oral Surgery at LifeSmiles Dental\">Oral Surgery<\/a><\/li>\r\n<\/ul>\r\n<details>\r\n<summary>View More Services<\/summary>\r\n<div class=\"details__content\">\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/extractions-wisdom-teeth-winnipeg\" class=\"cms-button-success\" title=\"Extractions &amp; Wisdom Tooth Removal at LifeSmiles Dental\">Extractions &amp; Wisdom Tooth Removal<\/a><\/li>\r\n<li><a href=\"\/site\/urgent-care-winnipeg\" class=\"cms-button-success\" title=\"Urgent Care at LifeSmiles Dental\">Urgent Care<\/a><\/li>\r\n<li><a href=\"\/site\/dental-sedation-winnipeg\" class=\"cms-button-success\" title=\"Dental Sedation at LifeSmiles Dental\">Dental Sedation<\/a><\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/details>","Multi Location Form Smartcode":"<div class="form-vertical">
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</script>","Practice Description":"","Practice NAP":"","Accepting New Patients":null}},{"id":"TIGM","name":"LifeSmiles Dental - Westminster","latitude":49.8816607,"longitude":-97.1596953,"geo":[49.8816607,-97.1596953],"google_place_id":"ChIJyz9Xufdz6lIR-uS1xV4LTZw","line1":"98 Sherbrook St","line2":"","full_address":"98 Sherbrook St  Winnipeg Canada R3C 2B3","postal_code":"R3C 2B3","locality":"Winnipeg","province":"Manitoba","country":"Canada","phone":"(204) 774-4296","website_url":"\/site\/contact\/winnipeg-dentist-westminster","shop_url":"","schedule":{"monday":{"start":"08:30","end":"17:00"},"tuesday":{"start":"08:30","end":"17:00"},"wednesday":{"start":"08:30","end":"17:00"},"thursday":{"start":"08:30","end":"17:00"},"friday":{"start":"08:30","end":"17:00"},"saturday":{"start":"00:00","end":"00:00"},"sunday":{"start":"00:00","end":"00:00"}},"isOpen":true,"customFields":{"Link to Google Maps":"https:\/\/maps.app.goo.gl\/EY7h8qGHpxmnoU4bA","Location":"Westminster","Multi Location Main Image":"\/files\/home-main-westminster.jpg","Multi Location Featured Services":"<h2>Featured Dental Services<\/h2>\r\n<p class=\"leadin\">We offer comprehensive dental care for the whole family, from children\u2019s services and Invisalign to restorative treatments like dental implants and dentures.<\/p>\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/preventive-dental-hygiene-winnipeg\" class=\"cms-button-success\" title=\"Preventive Hygiene at LifeSmiles Dental\">Preventive Hygiene<\/a><\/li>\r\n<li><a href=\"\/site\/children-dental-services-winnipeg\" class=\"cms-button-success\" title=\"Children's Dental Services at LifeSmiles Dental\">Children's Dental Services<\/a><\/li>\r\n<li><a href=\"\/site\/dental-implants-winnipeg\" class=\"cms-button-success\" title=\"Dental Implants at LifeSmiles Dental\">Dental Implants<\/a><\/li>\r\n<li><a href=\"\/site\/invisalign-clear-aligners-winnipeg\" class=\"cms-button-success\" title=\"Invisalign at LifeSmiles Dental\">Invisalign<\/a><\/li>\r\n<li><a href=\"\/site\/teeth-whitening-winnipeg\" class=\"cms-button-success\" title=\"Teeth Whitening at LifeSmiles Dental\">Teeth Whitening<\/a><\/li>\r\n<li><a href=\"\/site\/oral-surgery-winnipeg\" class=\"cms-button-success\" title=\"Oral Surgery at LifeSmiles Dental\">Oral Surgery<\/a><\/li>\r\n<\/ul>\r\n<details>\r\n<summary>View More Services<\/summary>\r\n<div class=\"details__content\">\r\n<ul class=\"list-buttons\">\r\n<li><a href=\"\/site\/extractions-wisdom-teeth-winnipeg\" class=\"cms-button-success\" title=\"Extractions &amp; Wisdom Tooth Removal at LifeSmiles Dental\">Extractions &amp; Wisdom Tooth Removal<\/a><\/li>\r\n<li><a href=\"\/site\/urgent-care-winnipeg\" class=\"cms-button-success\" title=\"Urgent Care at LifeSmiles Dental\">Urgent Care<\/a><\/li>\r\n<li><a href=\"\/site\/dental-sedation-winnipeg\" class=\"cms-button-success\" title=\"Dental Sedation at LifeSmiles Dental\">Dental Sedation<\/a><\/li>\r\n<\/ul>\r\n<\/div>\r\n<\/details>","Multi Location Form Smartcode":"<div class="form-vertical">
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      <span for="ifg-formfield-639-2" class="help-block"></span>
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  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-6">
    <label class="col-md-2  control-label " for="ifg-formfield-639-6" id="ifg-formfield-639-label-6">
      Phone              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Phone" type="text"  name="ifg-formfield-639-6" id="ifg-formfield-639-6" class="element_style_6  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-639-6" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
    
                      
              
                              <div class="form-group ifg-sort" role="group" aria-labelledby="ifg-formfield-639-label-7" id="ifg-element-div-7">
    <label class="col-md-2 control-label " id="ifg-formfield-639-label-7" role="presentation">
     Are you a new patient?            <span aria-hidden="true">*</span>
        </label>
    <div class="col-md-10">
                                                    <div class="" >
            <label for="ifg-formfield-639-7-0" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-639-7" id="ifg-formfield-639-7-0" class="" value="0"  required aria-required="true" data-cy="radio"/>
            Yes, I am a new patient</label>
          </div>
                                                <div class="" >
            <label for="ifg-formfield-639-7-1" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-639-7" id="ifg-formfield-639-7-1" class="" value="1"   data-cy="radio"/>
            No, I am already a patient</label>
          </div>
                                                <div class="" id="ifg-formfield-639-7">
            <label for="ifg-formfield-639-7-2" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-639-7" id="ifg-formfield-639-7-2" class="" value="2"   data-cy="radio"/>
            Other</label>
          </div>
                              <span for="ifg-formfield-639-7" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
    
                      
              
                          
  
  <div class="form-group ifg-sort" id="ifg-element-div-3">
    <label class="col-md-2  control-label " for="ifg-formfield-639-3" id="ifg-formfield-639-label-3">
      Message              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <textarea  name="ifg-formfield-639-3" id="ifg-formfield-639-3" class="element_style_3  form-control" required aria-required="true" data-cy="textarea"></textarea>
      <span for="ifg-formfield-639-3" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
          
        
        
  <div class="form-group ifg-sort" id="ifg-element-div-4">
    <label class="col-md-2 control-label " for="ifg-formfield-639-4" id="ifg-formfield-639-label-4">
    Spam Blocker         </label>
    <div class="col-md-10">
      <div id="recaptcha-4" class="captcha-recaptcha">
        <div class="show-captcha" ></div>
      </div>
      <span for="captchaSolution" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
    <div class="form-group">
    <div id="ifg-paragraph-8" class="paragraph-layout paragraph_style_8">
    By submitting this form, you confirm that you have read and agree to the practice's <a href="/site/privacy-policy" title="Privacy Policy" target="_blank">Privacy Policy</a>.     </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
      <div id="f1_upload_process-639" class="form-group" style="display:none;">
    <img src="/assets/images/manage/forms/loader.svg" width="32" alt="loader" />
  </div>
  <div class="form-group">
    <input type="submit" name="ifg-formfield-639-5" id="ifg-formfield-639-5" value="Submit" class="form-control element_style_5 event-submit-btn-639" onclick="submitClicked(639);return false;" data-cy="form-submit"/>
  </div>
  
  
  
  
  
  
  
<input type="hidden" name="form_id" value="59709" />
<input type="hidden" name="genRand_id" value="639" />
</form>



</div>
</div>

<script type="text/javascript">
  
  var ifgSubmitURL = "/cmsi-data/formdata";
  var ifgFileAttachEnabled_639 = false;
  
    jQuery().ready(function() {

      startUpload = function(generateRand2) {
        window.globalVar2 = generateRand2;
        document.getElementById('f1_upload_form-' + globalVar2).style.visibility = 'hidden';
        return true;
      }

      stopUpload = function(response) {
        if (response.success == true) {
          if (response.file_names) {
            jQuery.each(response.file_names, function(index, element) {
              jQuery("#ifg-formfield-" + globalVar + "-" + index).val(element);
            });
          }
          ajaxSubmit();
        } else {
          jQuery(".event-err").remove();
          jQuery.each(response.err, function(index, element) {
            jQuery("#ifg-formfield-" + globalVar + "-" + element.fileindex).after(element.err);
          });
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
        }
        return true;
      }

      ajaxSubmitWithFiles = function () {
        const ifgFileAttachEnabled = window["ifgFileAttachEnabled_" + globalVar];
        const ifgFileUploadMaxFilesize = 15 * 1024 * 1024;

        fillPhoneFieldsFull(globalVar);

        // Build FormData and collect files
        const frmData = new FormData(document.getElementById("ifgForm-" + globalVar));
        const oversizedFiles = [];
        let totalFileSize = 0;

        jQuery("#upload_form-" + globalVar + " input[type='file']").each(function () {
          if (this.files && this.files.length > 0) {
            const file = this.files[0];
            const fileIndex = jQuery(this).attr("id").split("-file-").pop();

            totalFileSize += file.size;

            if (ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
              oversizedFiles.push(
                file.name + ' (' + (totalFileSize / 1024 / 1024).toFixed(2) + 'MB exceeds ' +
                (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + 'MB limit)'
              );
              return;
            }

            const fieldKey = "ifg-formfield-" + globalVar + "-" + fileIndex + "_direct";
            frmData.append(fieldKey, file);
          }
        });

        // Total size check
        if (ifgFileAttachEnabled && ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">' +
            'Total upload size ' + (totalFileSize / 1024 / 1024).toFixed(2) + ' MB exceeds the ' +
            (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + ' MB limit.' +
            '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        if (oversizedFiles.length > 0) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">File too large: ' + oversizedFiles.join(', ') + '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        jQuery.ajax({
          url: ifgSubmitURL,
          data: frmData,
          type: "POST",
          async: true,
          dataType: "json",
          contentType: false,
          processData: false,
          success: function (response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function (xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      };

      jQuery("#ifgForm-639").validate({
        rules: { "ifg-formfield-639-0":"required","ifg-formfield-639-1":"required","ifg-formfield-639-2":{required: true, email: true},"ifg-formfield-639-6":"required","ifg-formfield-639-7":"required","ifg-formfield-639-3":"required","captchaSolution":"required" },
        messages: { "ifg-formfield-639-0": "This field is required.","ifg-formfield-639-1": "This field is required.","ifg-formfield-639-2": "Provide a valid email address.","ifg-formfield-639-6": "This field is required.","ifg-formfield-639-7": "Please select an option above.","ifg-formfield-639-3": "This field is required.","captchaSolution": "This field is required" },
        errorElement: 'span',
        errorPlacement: function(error, element) {
          error.insertAfter(element.closest('.col-md-10'));
        },
        errorClass: 'help-block',
        focusInvalid: true,
        ignore: "",
        invalidHandler: function(event, validator) {},
        highlight: function(element) {
          var form_id = jQuery(element).closest('form').attr('id');
          var splitFormID = form_id.split("-");
          var getFormID = splitFormID[1];
          jQuery(element).closest('.form-group').addClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').addClass('help-block-bg');
          jQuery("#f1_upload_process-" + getFormID).hide();
          jQuery(".event-submit-btn-" + getFormID).show();
        },
        unhighlight: function(element) {
          jQuery(element).closest('.form-group').removeClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').removeClass('help-block-bg');
        },
        success: function(label) {
          label.closest('.form-group').removeClass('has-error');
        },
        submitHandler: function(form) {
          var ifgFileAttachEnabled = window['ifgFileAttachEnabled_' + globalVar];

          var has_selected_file;
          jQuery('#upload_form-639').filter(function() {
            has_selected_file = true;
          }).length > 0;

          if (has_selected_file) {
            if (ifgFileAttachEnabled) {
              ajaxSubmitWithFiles();
            } else {
              jQuery("#upload_form-639").submit();
            }
          } else {
            ajaxSubmit();
          }
        }
      });

      jQuery.validator.addMethod(
        "ifgMaxFileSize",
        function (value, element, maxBytes) {
          if (!element.files || element.files.length === 0) {
            return true;
          }
          return element.files[0].size <= maxBytes;
        },
        "File too large (max {0} MB)"
      );

      submitClicked = function(generateRand) {
        window.globalVar = generateRand;
        jQuery("#f1_upload_process-" + globalVar).show();
        jQuery("#f1_upload_process-" + globalVar + " img").css({
          'border': '1px dotted rgb(204, 204, 204)',
          'border-radius': '17px',
          'background-color': '#ccc'
        });
        jQuery(".event-submit-btn-" + generateRand).hide();
        jQuery(".event-err").hide();
        jQuery(".alert").remove();
        jQuery(`#recaptcha-error-${generateRand}`).remove();

        function showRecaptchaError(error) {
          console.error("Error executing reCAPTCHA v3:", error);
          eleRecaptcha.closest('.form-group').addClass('has-error');
          jQuery(`<span id="recaptcha-error-${generateRand}" class="help-block help-block-bg">An error occurred. Please try again.</span>`).insertAfter(eleRecaptcha);
          jQuery("#f1_upload_process-" + generateRand).hide();
          jQuery(".event-submit-btn-" + generateRand).show();
        }

        let eleRecaptcha = $("#ifgForm-" + generateRand).find('div input[name="g-recaptcha-response"]');
        if (eleRecaptcha.length > 0) {
          try {
            grecaptcha.ready(function() {
              grecaptcha.execute('6LdiBt8ZAAAAAK_r5akjc-frIgBB8I0L8CwWJK7A', {action: "submit"}).then(function (token) {
                $(eleRecaptcha).val(token);
                jQuery("#ifgForm-" + generateRand).submit();
              }).catch(showRecaptchaError);
            });
          } catch (error) {
            showRecaptchaError(error);
            if (typeof Bugsnag !== "undefined" && Bugsnag.isStarted()) {
              Bugsnag.notify(new Error("Error executing reCAPTCHA v3: " + error.message), {
                severity: "error",
              });
            }
          }
        } else {
          jQuery("#ifgForm-" + generateRand).submit();
        }

      }

      selectUploadFile = function(generateRand, counter) {
        jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).click();
      }

      showFileNameSelected = function(generateRand, counter) {
        jQuery("#ifg-upload-" + generateRand + "-file-" + counter).html(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
        jQuery("#ifg-formfield-" + generateRand + "-" + counter).val(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
      }

      fillPhoneFieldsFull = function(globalVar) {
        for (const phoneObj of window['phoneObjects' + globalVar]) {
          document.getElementsByName(phoneObj.phoneFieldFullName)[0].value = phoneObj.intlTelInput.getNumber();
        }
      }

            ajaxSubmit = function() {
        fillPhoneFieldsFull(globalVar);
        var frmData = jQuery("#ifgForm-" + globalVar).serialize();
        jQuery.ajax({
          url: "/cmsi-data/formdata",
          data: frmData,
          type: "POST",
          async: false,
          dataType: "json",
          success: function(response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function(xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      }
      
      ifgSuccessCallback = function(response) {
                if (response.field_success == true) {
          var all_success = response.success;
          var displayAlert = true;
          if (typeof response.success_email != 'undefined' && response.success_email == true) {
            jQuery("#ifg-form-container").prepend(response.success_email_msg);
          } else if (typeof response.success_email != 'undefined' && response.success_email == false) {
            jQuery("#ifg-form-container").prepend(response.err_email_msg);
            all_success = false;
          }

          if (typeof response.success_action != 'undefined') {
            if (response.success_action == 'url-redirection' && typeof response.success_msg != 'undefined') {
              if (response.success_target == 'true') {

                jQuery("#ifgForm-"+globalVar).css("display","none");
                jQuery(".event-submit-btn-"+globalVar).css("display","none");
                jQuery("#ifgForm-"+globalVar).before("<div class='alert alert-success'>Sent.</div>");
                jQuery('html, body').animate({
                  scrollTop: jQuery(".alert").offset().top
                }, 500);
                window.open(response.success_msg, '_blank');
              } else {
                displayAlert = false;
                window.location.href = response.success_msg;
              }
            } else if (response.success_action == 'custom-msg' && typeof response.success_msg != 'undefined') {
              jQuery("#ifgForm-"+globalVar).before(response.success_msg);
            }
          }

          if ( displayAlert ){
            jQuery('html, body').animate({
              scrollTop: jQuery(".alert").offset().top
            }, 500);
          }

          jQuery("#ifgForm-"+globalVar).css("display","none");
          jQuery(".event-submit-btn-"+globalVar).css("display","none");
        } else {
          jQuery.each(response.field_err, function (index, element) {
            if ($("#" + element.field_name).closest("form").find("div.show-captcha").length > 0) {
              let recaptchaWidgetId = $("#" + element.field_name).closest("form").find("div.show-captcha").data().recaptchaWidget;
              if (typeof recaptchaWidgetId != 'undefined') {
                grecaptcha.reset(recaptchaWidgetId)
              }
            }
            jQuery("#" + element.field_name).after('<div class="has-error-' + globalVar + ' event-err"><span class="help-block-bg" style="color:#b94a48;">' + element.err + '</span></div>');
          });
        }
      }

    });
    

</script>","<div class="form-vertical">
<div class="ifg-preview-continer" id="ifg-form-container">
<form method="post" id="ifgForm-79" onsubmit="return false;" data-cy="form">

<script>
  
  if (typeof window.phoneObjects79 === 'undefined') {
    window.phoneObjects79 = [];
  }
  
</script>

  
  
  
  
  
                
    
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-0">
    <label class="col-md-2  control-label " for="ifg-formfield-79-0" id="ifg-formfield-79-label-0">
      First Name              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="First Name" type="text"  name="ifg-formfield-79-0" id="ifg-formfield-79-0" class="element_style_0  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-79-0" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-1">
    <label class="col-md-2  control-label " for="ifg-formfield-79-1" id="ifg-formfield-79-label-1">
      Last Name              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Last Name" type="text"  name="ifg-formfield-79-1" id="ifg-formfield-79-1" class="element_style_1  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-79-1" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
                          
                                            <div class="form-group ifg-sort" id="ifg-element-div-2">
    <label class="col-md-2  control-label " for="ifg-formfield-79-2" id="ifg-formfield-79-label-2">
      Email              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Email Address:" type="email"  name="ifg-formfield-79-2" id="ifg-formfield-79-2" class="element_style_2  form-control" required aria-required="true" data-cy="email"/>
      <span for="ifg-formfield-79-2" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-6">
    <label class="col-md-2  control-label " for="ifg-formfield-79-6" id="ifg-formfield-79-label-6">
      Phone              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Phone" type="text"  name="ifg-formfield-79-6" id="ifg-formfield-79-6" class="element_style_6  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-79-6" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
    
                      
              
                              <div class="form-group ifg-sort" role="group" aria-labelledby="ifg-formfield-79-label-7" id="ifg-element-div-7">
    <label class="col-md-2 control-label " id="ifg-formfield-79-label-7" role="presentation">
    Are you a new patient?            <span aria-hidden="true">*</span>
        </label>
    <div class="col-md-10">
                                                    <div class="" >
            <label for="ifg-formfield-79-7-0" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-79-7" id="ifg-formfield-79-7-0" class="" value="0"  required aria-required="true" data-cy="radio"/>
            Yes, I am a new patient</label>
          </div>
                                                <div class="" >
            <label for="ifg-formfield-79-7-1" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-79-7" id="ifg-formfield-79-7-1" class="" value="1"   data-cy="radio"/>
            No, I am already a patient</label>
          </div>
                                                <div class="" id="ifg-formfield-79-7">
            <label for="ifg-formfield-79-7-2" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-79-7" id="ifg-formfield-79-7-2" class="" value="2"   data-cy="radio"/>
            Other</label>
          </div>
                              <span for="ifg-formfield-79-7" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
    
                      
              
                          
  
  <div class="form-group ifg-sort" id="ifg-element-div-3">
    <label class="col-md-2  control-label " for="ifg-formfield-79-3" id="ifg-formfield-79-label-3">
      Message              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <textarea  name="ifg-formfield-79-3" id="ifg-formfield-79-3" class="element_style_3  form-control" required aria-required="true" data-cy="textarea"></textarea>
      <span for="ifg-formfield-79-3" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
          
        
        
  <div class="form-group ifg-sort" id="ifg-element-div-4">
    <label class="col-md-2 control-label " for="ifg-formfield-79-4" id="ifg-formfield-79-label-4">
    Spam Blocker         </label>
    <div class="col-md-10">
      <div id="recaptcha-4" class="captcha-recaptcha">
        <div class="show-captcha" ></div>
      </div>
      <span for="captchaSolution" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
    <div class="form-group">
    <div id="ifg-paragraph-8" class="paragraph-layout paragraph_style_8">
    By submitting this form, you confirm that you have read and agree to the practice's <a href="/site/privacy-policy" title="Privacy Policy" target="_blank">Privacy Policy</a>.     </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
      <div id="f1_upload_process-79" class="form-group" style="display:none;">
    <img src="/assets/images/manage/forms/loader.svg" width="32" alt="loader" />
  </div>
  <div class="form-group">
    <input type="submit" name="ifg-formfield-79-5" id="ifg-formfield-79-5" value="Submit" class="form-control element_style_5 event-submit-btn-79" onclick="submitClicked(79);return false;" data-cy="form-submit"/>
  </div>
  
  
  
  
  
  
  
<input type="hidden" name="form_id" value="59704" />
<input type="hidden" name="genRand_id" value="79" />
</form>



</div>
</div>

<script type="text/javascript">
  
  var ifgSubmitURL = "/cmsi-data/formdata";
  var ifgFileAttachEnabled_79 = false;
  
    jQuery().ready(function() {

      startUpload = function(generateRand2) {
        window.globalVar2 = generateRand2;
        document.getElementById('f1_upload_form-' + globalVar2).style.visibility = 'hidden';
        return true;
      }

      stopUpload = function(response) {
        if (response.success == true) {
          if (response.file_names) {
            jQuery.each(response.file_names, function(index, element) {
              jQuery("#ifg-formfield-" + globalVar + "-" + index).val(element);
            });
          }
          ajaxSubmit();
        } else {
          jQuery(".event-err").remove();
          jQuery.each(response.err, function(index, element) {
            jQuery("#ifg-formfield-" + globalVar + "-" + element.fileindex).after(element.err);
          });
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
        }
        return true;
      }

      ajaxSubmitWithFiles = function () {
        const ifgFileAttachEnabled = window["ifgFileAttachEnabled_" + globalVar];
        const ifgFileUploadMaxFilesize = 15 * 1024 * 1024;

        fillPhoneFieldsFull(globalVar);

        // Build FormData and collect files
        const frmData = new FormData(document.getElementById("ifgForm-" + globalVar));
        const oversizedFiles = [];
        let totalFileSize = 0;

        jQuery("#upload_form-" + globalVar + " input[type='file']").each(function () {
          if (this.files && this.files.length > 0) {
            const file = this.files[0];
            const fileIndex = jQuery(this).attr("id").split("-file-").pop();

            totalFileSize += file.size;

            if (ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
              oversizedFiles.push(
                file.name + ' (' + (totalFileSize / 1024 / 1024).toFixed(2) + 'MB exceeds ' +
                (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + 'MB limit)'
              );
              return;
            }

            const fieldKey = "ifg-formfield-" + globalVar + "-" + fileIndex + "_direct";
            frmData.append(fieldKey, file);
          }
        });

        // Total size check
        if (ifgFileAttachEnabled && ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">' +
            'Total upload size ' + (totalFileSize / 1024 / 1024).toFixed(2) + ' MB exceeds the ' +
            (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + ' MB limit.' +
            '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        if (oversizedFiles.length > 0) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">File too large: ' + oversizedFiles.join(', ') + '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        jQuery.ajax({
          url: ifgSubmitURL,
          data: frmData,
          type: "POST",
          async: true,
          dataType: "json",
          contentType: false,
          processData: false,
          success: function (response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function (xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      };

      jQuery("#ifgForm-79").validate({
        rules: { "ifg-formfield-79-0":"required","ifg-formfield-79-1":"required","ifg-formfield-79-2":{required: true, email: true},"ifg-formfield-79-6":"required","ifg-formfield-79-7":"required","ifg-formfield-79-3":"required","captchaSolution":"required" },
        messages: { "ifg-formfield-79-0": "This field is required.","ifg-formfield-79-1": "This field is required.","ifg-formfield-79-2": "Provide a valid email address.","ifg-formfield-79-6": "This field is required.","ifg-formfield-79-7": "Please select an option above.","ifg-formfield-79-3": "This field is required.","captchaSolution": "This field is required" },
        errorElement: 'span',
        errorPlacement: function(error, element) {
          error.insertAfter(element.closest('.col-md-10'));
        },
        errorClass: 'help-block',
        focusInvalid: true,
        ignore: "",
        invalidHandler: function(event, validator) {},
        highlight: function(element) {
          var form_id = jQuery(element).closest('form').attr('id');
          var splitFormID = form_id.split("-");
          var getFormID = splitFormID[1];
          jQuery(element).closest('.form-group').addClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').addClass('help-block-bg');
          jQuery("#f1_upload_process-" + getFormID).hide();
          jQuery(".event-submit-btn-" + getFormID).show();
        },
        unhighlight: function(element) {
          jQuery(element).closest('.form-group').removeClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').removeClass('help-block-bg');
        },
        success: function(label) {
          label.closest('.form-group').removeClass('has-error');
        },
        submitHandler: function(form) {
          var ifgFileAttachEnabled = window['ifgFileAttachEnabled_' + globalVar];

          var has_selected_file;
          jQuery('#upload_form-79').filter(function() {
            has_selected_file = true;
          }).length > 0;

          if (has_selected_file) {
            if (ifgFileAttachEnabled) {
              ajaxSubmitWithFiles();
            } else {
              jQuery("#upload_form-79").submit();
            }
          } else {
            ajaxSubmit();
          }
        }
      });

      jQuery.validator.addMethod(
        "ifgMaxFileSize",
        function (value, element, maxBytes) {
          if (!element.files || element.files.length === 0) {
            return true;
          }
          return element.files[0].size <= maxBytes;
        },
        "File too large (max {0} MB)"
      );

      submitClicked = function(generateRand) {
        window.globalVar = generateRand;
        jQuery("#f1_upload_process-" + globalVar).show();
        jQuery("#f1_upload_process-" + globalVar + " img").css({
          'border': '1px dotted rgb(204, 204, 204)',
          'border-radius': '17px',
          'background-color': '#ccc'
        });
        jQuery(".event-submit-btn-" + generateRand).hide();
        jQuery(".event-err").hide();
        jQuery(".alert").remove();
        jQuery(`#recaptcha-error-${generateRand}`).remove();

        function showRecaptchaError(error) {
          console.error("Error executing reCAPTCHA v3:", error);
          eleRecaptcha.closest('.form-group').addClass('has-error');
          jQuery(`<span id="recaptcha-error-${generateRand}" class="help-block help-block-bg">An error occurred. Please try again.</span>`).insertAfter(eleRecaptcha);
          jQuery("#f1_upload_process-" + generateRand).hide();
          jQuery(".event-submit-btn-" + generateRand).show();
        }

        let eleRecaptcha = $("#ifgForm-" + generateRand).find('div input[name="g-recaptcha-response"]');
        if (eleRecaptcha.length > 0) {
          try {
            grecaptcha.ready(function() {
              grecaptcha.execute('6LdiBt8ZAAAAAK_r5akjc-frIgBB8I0L8CwWJK7A', {action: "submit"}).then(function (token) {
                $(eleRecaptcha).val(token);
                jQuery("#ifgForm-" + generateRand).submit();
              }).catch(showRecaptchaError);
            });
          } catch (error) {
            showRecaptchaError(error);
            if (typeof Bugsnag !== "undefined" && Bugsnag.isStarted()) {
              Bugsnag.notify(new Error("Error executing reCAPTCHA v3: " + error.message), {
                severity: "error",
              });
            }
          }
        } else {
          jQuery("#ifgForm-" + generateRand).submit();
        }

      }

      selectUploadFile = function(generateRand, counter) {
        jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).click();
      }

      showFileNameSelected = function(generateRand, counter) {
        jQuery("#ifg-upload-" + generateRand + "-file-" + counter).html(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
        jQuery("#ifg-formfield-" + generateRand + "-" + counter).val(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
      }

      fillPhoneFieldsFull = function(globalVar) {
        for (const phoneObj of window['phoneObjects' + globalVar]) {
          document.getElementsByName(phoneObj.phoneFieldFullName)[0].value = phoneObj.intlTelInput.getNumber();
        }
      }

            ajaxSubmit = function() {
        fillPhoneFieldsFull(globalVar);
        var frmData = jQuery("#ifgForm-" + globalVar).serialize();
        jQuery.ajax({
          url: "/cmsi-data/formdata",
          data: frmData,
          type: "POST",
          async: false,
          dataType: "json",
          success: function(response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function(xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      }
      
      ifgSuccessCallback = function(response) {
                if (response.field_success == true) {
          var all_success = response.success;
          var displayAlert = true;
          if (typeof response.success_email != 'undefined' && response.success_email == true) {
            jQuery("#ifg-form-container").prepend(response.success_email_msg);
          } else if (typeof response.success_email != 'undefined' && response.success_email == false) {
            jQuery("#ifg-form-container").prepend(response.err_email_msg);
            all_success = false;
          }

          if (typeof response.success_action != 'undefined') {
            if (response.success_action == 'url-redirection' && typeof response.success_msg != 'undefined') {
              if (response.success_target == 'true') {

                jQuery("#ifgForm-"+globalVar).css("display","none");
                jQuery(".event-submit-btn-"+globalVar).css("display","none");
                jQuery("#ifgForm-"+globalVar).before("<div class='alert alert-success'>Sent.</div>");
                jQuery('html, body').animate({
                  scrollTop: jQuery(".alert").offset().top
                }, 500);
                window.open(response.success_msg, '_blank');
              } else {
                displayAlert = false;
                window.location.href = response.success_msg;
              }
            } else if (response.success_action == 'custom-msg' && typeof response.success_msg != 'undefined') {
              jQuery("#ifgForm-"+globalVar).before(response.success_msg);
            }
          }

          if ( displayAlert ){
            jQuery('html, body').animate({
              scrollTop: jQuery(".alert").offset().top
            }, 500);
          }

          jQuery("#ifgForm-"+globalVar).css("display","none");
          jQuery(".event-submit-btn-"+globalVar).css("display","none");
        } else {
          jQuery.each(response.field_err, function (index, element) {
            if ($("#" + element.field_name).closest("form").find("div.show-captcha").length > 0) {
              let recaptchaWidgetId = $("#" + element.field_name).closest("form").find("div.show-captcha").data().recaptchaWidget;
              if (typeof recaptchaWidgetId != 'undefined') {
                grecaptcha.reset(recaptchaWidgetId)
              }
            }
            jQuery("#" + element.field_name).after('<div class="has-error-' + globalVar + ' event-err"><span class="help-block-bg" style="color:#b94a48;">' + element.err + '</span></div>');
          });
        }
      }

    });
    

</script>","<div class="form-vertical">
<div class="ifg-preview-continer" id="ifg-form-container">
<form method="post" id="ifgForm-888" onsubmit="return false;" data-cy="form">

<script>
  
  if (typeof window.phoneObjects888 === 'undefined') {
    window.phoneObjects888 = [];
  }
  
</script>

  
  
  
  
  
                
    
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-0">
    <label class="col-md-2  control-label " for="ifg-formfield-888-0" id="ifg-formfield-888-label-0">
      First Name              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="First Name" type="text"  name="ifg-formfield-888-0" id="ifg-formfield-888-0" class="element_style_0  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-888-0" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-1">
    <label class="col-md-2  control-label " for="ifg-formfield-888-1" id="ifg-formfield-888-label-1">
      Last Name              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Last Name" type="text"  name="ifg-formfield-888-1" id="ifg-formfield-888-1" class="element_style_1  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-888-1" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
                          
                                            <div class="form-group ifg-sort" id="ifg-element-div-2">
    <label class="col-md-2  control-label " for="ifg-formfield-888-2" id="ifg-formfield-888-label-2">
      Email              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Email Address:" type="email"  name="ifg-formfield-888-2" id="ifg-formfield-888-2" class="element_style_2  form-control" required aria-required="true" data-cy="email"/>
      <span for="ifg-formfield-888-2" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-6">
    <label class="col-md-2  control-label " for="ifg-formfield-888-6" id="ifg-formfield-888-label-6">
      Phone              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Phone" type="text"  name="ifg-formfield-888-6" id="ifg-formfield-888-6" class="element_style_6  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-888-6" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
    
                      
              
                              <div class="form-group ifg-sort" role="group" aria-labelledby="ifg-formfield-888-label-7" id="ifg-element-div-7">
    <label class="col-md-2 control-label " id="ifg-formfield-888-label-7" role="presentation">
    Are you a new patient?            <span aria-hidden="true">*</span>
        </label>
    <div class="col-md-10">
                                                    <div class="" >
            <label for="ifg-formfield-888-7-0" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-888-7" id="ifg-formfield-888-7-0" class="" value="0"  required aria-required="true" data-cy="radio"/>
            Yes, I am a new patient</label>
          </div>
                                                <div class="" >
            <label for="ifg-formfield-888-7-1" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-888-7" id="ifg-formfield-888-7-1" class="" value="1"   data-cy="radio"/>
            No, I am already a patient</label>
          </div>
                                                <div class="" id="ifg-formfield-888-7">
            <label for="ifg-formfield-888-7-2" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-888-7" id="ifg-formfield-888-7-2" class="" value="2"   data-cy="radio"/>
            Other</label>
          </div>
                              <span for="ifg-formfield-888-7" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
    
                      
              
                          
  
  <div class="form-group ifg-sort" id="ifg-element-div-3">
    <label class="col-md-2  control-label " for="ifg-formfield-888-3" id="ifg-formfield-888-label-3">
      Message              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <textarea  name="ifg-formfield-888-3" id="ifg-formfield-888-3" class="element_style_3  form-control" required aria-required="true" data-cy="textarea"></textarea>
      <span for="ifg-formfield-888-3" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
          
        
        
  <div class="form-group ifg-sort" id="ifg-element-div-4">
    <label class="col-md-2 control-label " for="ifg-formfield-888-4" id="ifg-formfield-888-label-4">
    Spam Blocker         </label>
    <div class="col-md-10">
      <div id="recaptcha-4" class="captcha-recaptcha">
        <div class="show-captcha" ></div>
      </div>
      <span for="captchaSolution" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
    <div class="form-group">
    <div id="ifg-paragraph-8" class="paragraph-layout paragraph_style_8">
    By submitting this form, you confirm that you have read and agree to the practice's <a href="/site/privacy-policy" title="Privacy Policy" target="_blank">Privacy Policy</a>.     </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
      <div id="f1_upload_process-888" class="form-group" style="display:none;">
    <img src="/assets/images/manage/forms/loader.svg" width="32" alt="loader" />
  </div>
  <div class="form-group">
    <input type="submit" name="ifg-formfield-888-5" id="ifg-formfield-888-5" value="Submit" class="form-control element_style_5 event-submit-btn-888" onclick="submitClicked(888);return false;" data-cy="form-submit"/>
  </div>
  
  
  
  
  
  
  
<input type="hidden" name="form_id" value="59708" />
<input type="hidden" name="genRand_id" value="888" />
</form>



</div>
</div>

<script type="text/javascript">
  
  var ifgSubmitURL = "/cmsi-data/formdata";
  var ifgFileAttachEnabled_888 = false;
  
    jQuery().ready(function() {

      startUpload = function(generateRand2) {
        window.globalVar2 = generateRand2;
        document.getElementById('f1_upload_form-' + globalVar2).style.visibility = 'hidden';
        return true;
      }

      stopUpload = function(response) {
        if (response.success == true) {
          if (response.file_names) {
            jQuery.each(response.file_names, function(index, element) {
              jQuery("#ifg-formfield-" + globalVar + "-" + index).val(element);
            });
          }
          ajaxSubmit();
        } else {
          jQuery(".event-err").remove();
          jQuery.each(response.err, function(index, element) {
            jQuery("#ifg-formfield-" + globalVar + "-" + element.fileindex).after(element.err);
          });
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
        }
        return true;
      }

      ajaxSubmitWithFiles = function () {
        const ifgFileAttachEnabled = window["ifgFileAttachEnabled_" + globalVar];
        const ifgFileUploadMaxFilesize = 15 * 1024 * 1024;

        fillPhoneFieldsFull(globalVar);

        // Build FormData and collect files
        const frmData = new FormData(document.getElementById("ifgForm-" + globalVar));
        const oversizedFiles = [];
        let totalFileSize = 0;

        jQuery("#upload_form-" + globalVar + " input[type='file']").each(function () {
          if (this.files && this.files.length > 0) {
            const file = this.files[0];
            const fileIndex = jQuery(this).attr("id").split("-file-").pop();

            totalFileSize += file.size;

            if (ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
              oversizedFiles.push(
                file.name + ' (' + (totalFileSize / 1024 / 1024).toFixed(2) + 'MB exceeds ' +
                (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + 'MB limit)'
              );
              return;
            }

            const fieldKey = "ifg-formfield-" + globalVar + "-" + fileIndex + "_direct";
            frmData.append(fieldKey, file);
          }
        });

        // Total size check
        if (ifgFileAttachEnabled && ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">' +
            'Total upload size ' + (totalFileSize / 1024 / 1024).toFixed(2) + ' MB exceeds the ' +
            (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + ' MB limit.' +
            '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        if (oversizedFiles.length > 0) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">File too large: ' + oversizedFiles.join(', ') + '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        jQuery.ajax({
          url: ifgSubmitURL,
          data: frmData,
          type: "POST",
          async: true,
          dataType: "json",
          contentType: false,
          processData: false,
          success: function (response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function (xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      };

      jQuery("#ifgForm-888").validate({
        rules: { "ifg-formfield-888-0":"required","ifg-formfield-888-1":"required","ifg-formfield-888-2":{required: true, email: true},"ifg-formfield-888-6":"required","ifg-formfield-888-7":"required","ifg-formfield-888-3":"required","captchaSolution":"required" },
        messages: { "ifg-formfield-888-0": "This field is required.","ifg-formfield-888-1": "This field is required.","ifg-formfield-888-2": "Provide a valid email address.","ifg-formfield-888-6": "This field is required.","ifg-formfield-888-7": "Please select an option above.","ifg-formfield-888-3": "This field is required.","captchaSolution": "This field is required" },
        errorElement: 'span',
        errorPlacement: function(error, element) {
          error.insertAfter(element.closest('.col-md-10'));
        },
        errorClass: 'help-block',
        focusInvalid: true,
        ignore: "",
        invalidHandler: function(event, validator) {},
        highlight: function(element) {
          var form_id = jQuery(element).closest('form').attr('id');
          var splitFormID = form_id.split("-");
          var getFormID = splitFormID[1];
          jQuery(element).closest('.form-group').addClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').addClass('help-block-bg');
          jQuery("#f1_upload_process-" + getFormID).hide();
          jQuery(".event-submit-btn-" + getFormID).show();
        },
        unhighlight: function(element) {
          jQuery(element).closest('.form-group').removeClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').removeClass('help-block-bg');
        },
        success: function(label) {
          label.closest('.form-group').removeClass('has-error');
        },
        submitHandler: function(form) {
          var ifgFileAttachEnabled = window['ifgFileAttachEnabled_' + globalVar];

          var has_selected_file;
          jQuery('#upload_form-888').filter(function() {
            has_selected_file = true;
          }).length > 0;

          if (has_selected_file) {
            if (ifgFileAttachEnabled) {
              ajaxSubmitWithFiles();
            } else {
              jQuery("#upload_form-888").submit();
            }
          } else {
            ajaxSubmit();
          }
        }
      });

      jQuery.validator.addMethod(
        "ifgMaxFileSize",
        function (value, element, maxBytes) {
          if (!element.files || element.files.length === 0) {
            return true;
          }
          return element.files[0].size <= maxBytes;
        },
        "File too large (max {0} MB)"
      );

      submitClicked = function(generateRand) {
        window.globalVar = generateRand;
        jQuery("#f1_upload_process-" + globalVar).show();
        jQuery("#f1_upload_process-" + globalVar + " img").css({
          'border': '1px dotted rgb(204, 204, 204)',
          'border-radius': '17px',
          'background-color': '#ccc'
        });
        jQuery(".event-submit-btn-" + generateRand).hide();
        jQuery(".event-err").hide();
        jQuery(".alert").remove();
        jQuery(`#recaptcha-error-${generateRand}`).remove();

        function showRecaptchaError(error) {
          console.error("Error executing reCAPTCHA v3:", error);
          eleRecaptcha.closest('.form-group').addClass('has-error');
          jQuery(`<span id="recaptcha-error-${generateRand}" class="help-block help-block-bg">An error occurred. Please try again.</span>`).insertAfter(eleRecaptcha);
          jQuery("#f1_upload_process-" + generateRand).hide();
          jQuery(".event-submit-btn-" + generateRand).show();
        }

        let eleRecaptcha = $("#ifgForm-" + generateRand).find('div input[name="g-recaptcha-response"]');
        if (eleRecaptcha.length > 0) {
          try {
            grecaptcha.ready(function() {
              grecaptcha.execute('6LdiBt8ZAAAAAK_r5akjc-frIgBB8I0L8CwWJK7A', {action: "submit"}).then(function (token) {
                $(eleRecaptcha).val(token);
                jQuery("#ifgForm-" + generateRand).submit();
              }).catch(showRecaptchaError);
            });
          } catch (error) {
            showRecaptchaError(error);
            if (typeof Bugsnag !== "undefined" && Bugsnag.isStarted()) {
              Bugsnag.notify(new Error("Error executing reCAPTCHA v3: " + error.message), {
                severity: "error",
              });
            }
          }
        } else {
          jQuery("#ifgForm-" + generateRand).submit();
        }

      }

      selectUploadFile = function(generateRand, counter) {
        jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).click();
      }

      showFileNameSelected = function(generateRand, counter) {
        jQuery("#ifg-upload-" + generateRand + "-file-" + counter).html(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
        jQuery("#ifg-formfield-" + generateRand + "-" + counter).val(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
      }

      fillPhoneFieldsFull = function(globalVar) {
        for (const phoneObj of window['phoneObjects' + globalVar]) {
          document.getElementsByName(phoneObj.phoneFieldFullName)[0].value = phoneObj.intlTelInput.getNumber();
        }
      }

            ajaxSubmit = function() {
        fillPhoneFieldsFull(globalVar);
        var frmData = jQuery("#ifgForm-" + globalVar).serialize();
        jQuery.ajax({
          url: "/cmsi-data/formdata",
          data: frmData,
          type: "POST",
          async: false,
          dataType: "json",
          success: function(response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function(xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      }
      
      ifgSuccessCallback = function(response) {
                if (response.field_success == true) {
          var all_success = response.success;
          var displayAlert = true;
          if (typeof response.success_email != 'undefined' && response.success_email == true) {
            jQuery("#ifg-form-container").prepend(response.success_email_msg);
          } else if (typeof response.success_email != 'undefined' && response.success_email == false) {
            jQuery("#ifg-form-container").prepend(response.err_email_msg);
            all_success = false;
          }

          if (typeof response.success_action != 'undefined') {
            if (response.success_action == 'url-redirection' && typeof response.success_msg != 'undefined') {
              if (response.success_target == 'true') {

                jQuery("#ifgForm-"+globalVar).css("display","none");
                jQuery(".event-submit-btn-"+globalVar).css("display","none");
                jQuery("#ifgForm-"+globalVar).before("<div class='alert alert-success'>Sent.</div>");
                jQuery('html, body').animate({
                  scrollTop: jQuery(".alert").offset().top
                }, 500);
                window.open(response.success_msg, '_blank');
              } else {
                displayAlert = false;
                window.location.href = response.success_msg;
              }
            } else if (response.success_action == 'custom-msg' && typeof response.success_msg != 'undefined') {
              jQuery("#ifgForm-"+globalVar).before(response.success_msg);
            }
          }

          if ( displayAlert ){
            jQuery('html, body').animate({
              scrollTop: jQuery(".alert").offset().top
            }, 500);
          }

          jQuery("#ifgForm-"+globalVar).css("display","none");
          jQuery(".event-submit-btn-"+globalVar).css("display","none");
        } else {
          jQuery.each(response.field_err, function (index, element) {
            if ($("#" + element.field_name).closest("form").find("div.show-captcha").length > 0) {
              let recaptchaWidgetId = $("#" + element.field_name).closest("form").find("div.show-captcha").data().recaptchaWidget;
              if (typeof recaptchaWidgetId != 'undefined') {
                grecaptcha.reset(recaptchaWidgetId)
              }
            }
            jQuery("#" + element.field_name).after('<div class="has-error-' + globalVar + ' event-err"><span class="help-block-bg" style="color:#b94a48;">' + element.err + '</span></div>');
          });
        }
      }

    });
    

</script>","<div class="form-vertical">
<div class="ifg-preview-continer" id="ifg-form-container">
<form method="post" id="ifgForm-510" onsubmit="return false;" data-cy="form">

<script>
  
  if (typeof window.phoneObjects510 === 'undefined') {
    window.phoneObjects510 = [];
  }
  
</script>

  
  
  
  
  
                
    
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-0">
    <label class="col-md-2  control-label " for="ifg-formfield-510-0" id="ifg-formfield-510-label-0">
      First Name              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="First Name" type="text"  name="ifg-formfield-510-0" id="ifg-formfield-510-0" class="element_style_0  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-510-0" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-1">
    <label class="col-md-2  control-label " for="ifg-formfield-510-1" id="ifg-formfield-510-label-1">
      Last Name              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Last Name" type="text"  name="ifg-formfield-510-1" id="ifg-formfield-510-1" class="element_style_1  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-510-1" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
                          
                                            <div class="form-group ifg-sort" id="ifg-element-div-2">
    <label class="col-md-2  control-label " for="ifg-formfield-510-2" id="ifg-formfield-510-label-2">
      Email              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Email Address:" type="email"  name="ifg-formfield-510-2" id="ifg-formfield-510-2" class="element_style_2  form-control" required aria-required="true" data-cy="email"/>
      <span for="ifg-formfield-510-2" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                          
              
                  
    
        <div class="form-group ifg-sort" id="ifg-element-div-6">
    <label class="col-md-2  control-label " for="ifg-formfield-510-6" id="ifg-formfield-510-label-6">
      Phone              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <input data-field-name="Phone" type="text"  name="ifg-formfield-510-6" id="ifg-formfield-510-6" class="element_style_6  form-control" required aria-required="true" data-cy="text"/>
      <span for="ifg-formfield-510-6" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
    
                      
              
                              <div class="form-group ifg-sort" role="group" aria-labelledby="ifg-formfield-510-label-7" id="ifg-element-div-7">
    <label class="col-md-2 control-label " id="ifg-formfield-510-label-7" role="presentation">
    Are you a new patient?            <span aria-hidden="true">*</span>
        </label>
    <div class="col-md-10">
                                                    <div class="" >
            <label for="ifg-formfield-510-7-0" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-510-7" id="ifg-formfield-510-7-0" class="" value="0"  required aria-required="true" data-cy="radio"/>
            Yes, I am a new patient</label>
          </div>
                                                <div class="" >
            <label for="ifg-formfield-510-7-1" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-510-7" id="ifg-formfield-510-7-1" class="" value="1"   data-cy="radio"/>
            No, I am already a patient</label>
          </div>
                                                <div class="" id="ifg-formfield-510-7">
            <label for="ifg-formfield-510-7-2" class="element_style_7  ">
            <input type="radio" name="ifg-formfield-510-7" id="ifg-formfield-510-7-2" class="" value="2"   data-cy="radio"/>
            Other</label>
          </div>
                              <span for="ifg-formfield-510-7" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
    
                      
              
                          
  
  <div class="form-group ifg-sort" id="ifg-element-div-3">
    <label class="col-md-2  control-label " for="ifg-formfield-510-3" id="ifg-formfield-510-label-3">
      Message              <span aria-hidden="true">*</span>
      
    </label>
    <div class="col-md-10">
      <textarea  name="ifg-formfield-510-3" id="ifg-formfield-510-3" class="element_style_3  form-control" required aria-required="true" data-cy="textarea"></textarea>
      <span for="ifg-formfield-510-3" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
          
        
        
  <div class="form-group ifg-sort" id="ifg-element-div-4">
    <label class="col-md-2 control-label " for="ifg-formfield-510-4" id="ifg-formfield-510-label-4">
    Spam Blocker         </label>
    <div class="col-md-10">
      <div id="recaptcha-4" class="captcha-recaptcha">
        <div class="show-captcha" ></div>
      </div>
      <span for="captchaSolution" class="help-block"></span>
          </div>
  </div>
  
  
  
  
  
  
  
  
  
  
    <div class="form-group">
    <div id="ifg-paragraph-8" class="paragraph-layout paragraph_style_8">
    By submitting this form, you confirm that you have read and agree to the practice's <a href="/site/privacy-policy" title="Privacy Policy" target="_blank">Privacy Policy</a>.     </div>
  </div>
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
      <div id="f1_upload_process-510" class="form-group" style="display:none;">
    <img src="/assets/images/manage/forms/loader.svg" width="32" alt="loader" />
  </div>
  <div class="form-group">
    <input type="submit" name="ifg-formfield-510-5" id="ifg-formfield-510-5" value="Submit" class="form-control element_style_5 event-submit-btn-510" onclick="submitClicked(510);return false;" data-cy="form-submit"/>
  </div>
  
  
  
  
  
  
  
<input type="hidden" name="form_id" value="59706" />
<input type="hidden" name="genRand_id" value="510" />
</form>



</div>
</div>

<script type="text/javascript">
  
  var ifgSubmitURL = "/cmsi-data/formdata";
  var ifgFileAttachEnabled_510 = false;
  
    jQuery().ready(function() {

      startUpload = function(generateRand2) {
        window.globalVar2 = generateRand2;
        document.getElementById('f1_upload_form-' + globalVar2).style.visibility = 'hidden';
        return true;
      }

      stopUpload = function(response) {
        if (response.success == true) {
          if (response.file_names) {
            jQuery.each(response.file_names, function(index, element) {
              jQuery("#ifg-formfield-" + globalVar + "-" + index).val(element);
            });
          }
          ajaxSubmit();
        } else {
          jQuery(".event-err").remove();
          jQuery.each(response.err, function(index, element) {
            jQuery("#ifg-formfield-" + globalVar + "-" + element.fileindex).after(element.err);
          });
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
        }
        return true;
      }

      ajaxSubmitWithFiles = function () {
        const ifgFileAttachEnabled = window["ifgFileAttachEnabled_" + globalVar];
        const ifgFileUploadMaxFilesize = 15 * 1024 * 1024;

        fillPhoneFieldsFull(globalVar);

        // Build FormData and collect files
        const frmData = new FormData(document.getElementById("ifgForm-" + globalVar));
        const oversizedFiles = [];
        let totalFileSize = 0;

        jQuery("#upload_form-" + globalVar + " input[type='file']").each(function () {
          if (this.files && this.files.length > 0) {
            const file = this.files[0];
            const fileIndex = jQuery(this).attr("id").split("-file-").pop();

            totalFileSize += file.size;

            if (ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
              oversizedFiles.push(
                file.name + ' (' + (totalFileSize / 1024 / 1024).toFixed(2) + 'MB exceeds ' +
                (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + 'MB limit)'
              );
              return;
            }

            const fieldKey = "ifg-formfield-" + globalVar + "-" + fileIndex + "_direct";
            frmData.append(fieldKey, file);
          }
        });

        // Total size check
        if (ifgFileAttachEnabled && ifgFileUploadMaxFilesize > 0 && totalFileSize > ifgFileUploadMaxFilesize) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">' +
            'Total upload size ' + (totalFileSize / 1024 / 1024).toFixed(2) + ' MB exceeds the ' +
            (ifgFileUploadMaxFilesize / 1024 / 1024).toFixed(2) + ' MB limit.' +
            '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        if (oversizedFiles.length > 0) {
          jQuery("#f1_upload_process-" + globalVar).hide();
          jQuery(".event-submit-btn-" + globalVar).show();
          jQuery(".event-err").remove();
          jQuery("#ifgForm-" + globalVar).before(
            '<div class="has-error event-err"><span class="help-block-bg" style="color:#b94a48;">File too large: ' + oversizedFiles.join(', ') + '</span></div>'
          );
          jQuery("html, body").animate({ scrollTop: jQuery(".event-err").offset().top }, 500);
          return;
        }

        jQuery.ajax({
          url: ifgSubmitURL,
          data: frmData,
          type: "POST",
          async: true,
          dataType: "json",
          contentType: false,
          processData: false,
          success: function (response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function (xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      };

      jQuery("#ifgForm-510").validate({
        rules: { "ifg-formfield-510-0":"required","ifg-formfield-510-1":"required","ifg-formfield-510-2":{required: true, email: true},"ifg-formfield-510-6":"required","ifg-formfield-510-7":"required","ifg-formfield-510-3":"required","captchaSolution":"required" },
        messages: { "ifg-formfield-510-0": "This field is required.","ifg-formfield-510-1": "This field is required.","ifg-formfield-510-2": "Provide a valid email address.","ifg-formfield-510-6": "This field is required.","ifg-formfield-510-7": "Please select an option above.","ifg-formfield-510-3": "This field is required.","captchaSolution": "This field is required" },
        errorElement: 'span',
        errorPlacement: function(error, element) {
          error.insertAfter(element.closest('.col-md-10'));
        },
        errorClass: 'help-block',
        focusInvalid: true,
        ignore: "",
        invalidHandler: function(event, validator) {},
        highlight: function(element) {
          var form_id = jQuery(element).closest('form').attr('id');
          var splitFormID = form_id.split("-");
          var getFormID = splitFormID[1];
          jQuery(element).closest('.form-group').addClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').addClass('help-block-bg');
          jQuery("#f1_upload_process-" + getFormID).hide();
          jQuery(".event-submit-btn-" + getFormID).show();
        },
        unhighlight: function(element) {
          jQuery(element).closest('.form-group').removeClass('has-error');
          jQuery(element).closest('.form-group').find('.help-block').removeClass('help-block-bg');
        },
        success: function(label) {
          label.closest('.form-group').removeClass('has-error');
        },
        submitHandler: function(form) {
          var ifgFileAttachEnabled = window['ifgFileAttachEnabled_' + globalVar];

          var has_selected_file;
          jQuery('#upload_form-510').filter(function() {
            has_selected_file = true;
          }).length > 0;

          if (has_selected_file) {
            if (ifgFileAttachEnabled) {
              ajaxSubmitWithFiles();
            } else {
              jQuery("#upload_form-510").submit();
            }
          } else {
            ajaxSubmit();
          }
        }
      });

      jQuery.validator.addMethod(
        "ifgMaxFileSize",
        function (value, element, maxBytes) {
          if (!element.files || element.files.length === 0) {
            return true;
          }
          return element.files[0].size <= maxBytes;
        },
        "File too large (max {0} MB)"
      );

      submitClicked = function(generateRand) {
        window.globalVar = generateRand;
        jQuery("#f1_upload_process-" + globalVar).show();
        jQuery("#f1_upload_process-" + globalVar + " img").css({
          'border': '1px dotted rgb(204, 204, 204)',
          'border-radius': '17px',
          'background-color': '#ccc'
        });
        jQuery(".event-submit-btn-" + generateRand).hide();
        jQuery(".event-err").hide();
        jQuery(".alert").remove();
        jQuery(`#recaptcha-error-${generateRand}`).remove();

        function showRecaptchaError(error) {
          console.error("Error executing reCAPTCHA v3:", error);
          eleRecaptcha.closest('.form-group').addClass('has-error');
          jQuery(`<span id="recaptcha-error-${generateRand}" class="help-block help-block-bg">An error occurred. Please try again.</span>`).insertAfter(eleRecaptcha);
          jQuery("#f1_upload_process-" + generateRand).hide();
          jQuery(".event-submit-btn-" + generateRand).show();
        }

        let eleRecaptcha = $("#ifgForm-" + generateRand).find('div input[name="g-recaptcha-response"]');
        if (eleRecaptcha.length > 0) {
          try {
            grecaptcha.ready(function() {
              grecaptcha.execute('6LdiBt8ZAAAAAK_r5akjc-frIgBB8I0L8CwWJK7A', {action: "submit"}).then(function (token) {
                $(eleRecaptcha).val(token);
                jQuery("#ifgForm-" + generateRand).submit();
              }).catch(showRecaptchaError);
            });
          } catch (error) {
            showRecaptchaError(error);
            if (typeof Bugsnag !== "undefined" && Bugsnag.isStarted()) {
              Bugsnag.notify(new Error("Error executing reCAPTCHA v3: " + error.message), {
                severity: "error",
              });
            }
          }
        } else {
          jQuery("#ifgForm-" + generateRand).submit();
        }

      }

      selectUploadFile = function(generateRand, counter) {
        jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).click();
      }

      showFileNameSelected = function(generateRand, counter) {
        jQuery("#ifg-upload-" + generateRand + "-file-" + counter).html(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
        jQuery("#ifg-formfield-" + generateRand + "-" + counter).val(
          jQuery("#ifg-formfield-" + generateRand + "-file-" + counter).val().split('\\').pop()
        );
      }

      fillPhoneFieldsFull = function(globalVar) {
        for (const phoneObj of window['phoneObjects' + globalVar]) {
          document.getElementsByName(phoneObj.phoneFieldFullName)[0].value = phoneObj.intlTelInput.getNumber();
        }
      }

            ajaxSubmit = function() {
        fillPhoneFieldsFull(globalVar);
        var frmData = jQuery("#ifgForm-" + globalVar).serialize();
        jQuery.ajax({
          url: "/cmsi-data/formdata",
          data: frmData,
          type: "POST",
          async: false,
          dataType: "json",
          success: function(response) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
            ifgSuccessCallback(response);
          },
          error: function(xhr, err) {
            jQuery("#f1_upload_process-" + globalVar).hide();
            jQuery(".event-submit-btn-" + globalVar).show();
          }
        });
      }
      
      ifgSuccessCallback = function(response) {
                if (response.field_success == true) {
          var all_success = response.success;
          var displayAlert = true;
          if (typeof response.success_email != 'undefined' && response.success_email == true) {
            jQuery("#ifg-form-container").prepend(response.success_email_msg);
          } else if (typeof response.success_email != 'undefined' && response.success_email == false) {
            jQuery("#ifg-form-container").prepend(response.err_email_msg);
            all_success = false;
          }

          if (typeof response.success_action != 'undefined') {
            if (response.success_action == 'url-redirection' && typeof response.success_msg != 'undefined') {
              if (response.success_target == 'true') {

                jQuery("#ifgForm-"+globalVar).css("display","none");
                jQuery(".event-submit-btn-"+globalVar).css("display","none");
                jQuery("#ifgForm-"+globalVar).before("<div class='alert alert-success'>Sent.</div>");
                jQuery('html, body').animate({
                  scrollTop: jQuery(".alert").offset().top
                }, 500);
                window.open(response.success_msg, '_blank');
              } else {
                displayAlert = false;
                window.location.href = response.success_msg;
              }
            } else if (response.success_action == 'custom-msg' && typeof response.success_msg != 'undefined') {
              jQuery("#ifgForm-"+globalVar).before(response.success_msg);
            }
          }

          if ( displayAlert ){
            jQuery('html, body').animate({
              scrollTop: jQuery(".alert").offset().top
            }, 500);
          }

          jQuery("#ifgForm-"+globalVar).css("display","none");
          jQuery(".event-submit-btn-"+globalVar).css("display","none");
        } else {
          jQuery.each(response.field_err, function (index, element) {
            if ($("#" + element.field_name).closest("form").find("div.show-captcha").length > 0) {
              let recaptchaWidgetId = $("#" + element.field_name).closest("form").find("div.show-captcha").data().recaptchaWidget;
              if (typeof recaptchaWidgetId != 'undefined') {
                grecaptcha.reset(recaptchaWidgetId)
              }
            }
            jQuery("#" + element.field_name).after('<div class="has-error-' + globalVar + ' event-err"><span class="help-block-bg" style="color:#b94a48;">' + element.err + '</span></div>');
          });
        }
      }

    });
    

</script>"],"Practice Description":[""],"Practice NAP":[""],"Accepting New Patients":[]}}