File: /home/trustedhealthcareproviders/public_html/lp/form.php
<?php include("header.php"); ?>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="https://code.jquery.com/ui/1.12.1/jquery-ui.js"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/jquery.validate.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery.mask/1.14.15/jquery.mask.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-ui-timepicker-addon/1.6.3/jquery-ui-timepicker-addon.min.js"></script>
<style>
input:invalid+span:after {
contepxnt: '✖';
padding-left: 5px;
color: red;
}
input:valid+span:after {
content: '✓';
padding-left: 5px;
color:green;
}
.hero-1-bg {
padding: 170px 0 30px !important;
}
.disclaimer {
color: #bcbdcc !important;
font-size:12px !important;
}
.home-section2 {
padding-top: 138px !important;
padding-bottom: 50px !important;
}
input.register-input, select.register-input {
color:#757a7f !important;
}
input.register-input, select.register-input {
width: 100%!important;
height: 60px!important;
padding-left: 3%!important;
padding-right: 5%!important;
margin-bottom: 15px!important;
color: #757a7f !important;
border: 2px solid #0387cb;
background-color: #fff;
font-size: 16px!important;
border-radius: 2px !important;
}
input.register-submit {
background: #0387cb !important;
border: none;
color: #fff;
letter-spacing: 1px;
cursor: pointer;
display: inline-block;
font-size: 14px;
font-weight: 700;
width: 100%;
padding: 20px 0;
text-transform: uppercase;
-webkit-border-radius: 3px 3px;
-moz-border-radius: 3px 3px;
border-radius: 3px 3px;
transition: all .50s ease-in-out;
-moz-transition: all .50s ease-in-out;
-webkit-transition: all .50s ease-in-out;
}
.error {
color:#C92228 !important;
}
</style>
<!--begin home section -->
<section class="home-section2" id="home">
<div class="home-section-overlay"></div>
<!--begin container -->
<div class="container">
<!--begin row -->
<div class="row">
<!--begin col-md-6-->
<div class="col-md-6 margin-top-40 hero-content">
<h1 style="color: #fff !important;">Contact Us</h1>
<p class="hero-text" style="color: #fff !important;">Discover the future of healthcare with Trusted Healthcare Providers.</p>
<!--begin newsletter_form_box -->
<div class="newsletter_form_box">
<!--begin success_box -->
<p class="newsletter_success_box" style="display:none;">We received your message and you'll hear from us soon. Thank You!</p>
<!--end success_box -->
<!--begin newsletter-form -->
</div>
<!--end newsletter_form_box -->
</div>
<!--end col-md-6-->
<!--begin col-md-6-->
<div class="col-md-6">
</div>
<!--end col-md-6-->
</div>
<!--end row -->
</div>
<!--end container -->
</section>
<!--end home section -->
<section class="section-grey" id="contact">
<!--begin container-->
<div class="container">
<!--begin row -->
<div class="row">
<!--begin col-md-12-->
<div class="col-md-12 text-center padding-bottom-10">
<h3 class="section-title">Get Your Free Consultation</h3>
<p class="section-subtitle">Call us toll-free at <a href="Tel: +1 (844) 405-1487">(844) 405-1487</a> or fill out the form to get in touch.</b></p>
</div>
<!--end col-md-12 -->
</div>
<!--end row -->
<!--begin row-->
<div class="row justify-content-md-center">
<!--begin col-md-8-->
<div class="col-md-12 text-center margin-top-10">
<!--begin register-form-wrapper-->
<div class="register-form-wrapper wow bounceIn" data-wow-delay="0.5s" style="visibility: visible; animation-delay: 0.5s; animation-name: bounceIn;">
<!--begin form-->
<div>
<!--begin success message -->
<p class="register_success_box" style="display:none;">We received your message and you will hear from us soon. Thank You!</p>
<!--end success message -->
<!--begin register form -->
<form id="valForm" name="valForm" method="get">
<!------------------------------------------------>
<!-- Personal Information -->
<!------------------------------------------------>
<div class="row">
<div class="col-sm-12">
<h4 class="text-left"> Contact Information</h4>
</div>
<div class="col-sm-6 form-group">
<input type="text" id="firstname" class="register-input" name="firstname" placeholder="First Name*" required>
</div>
<div class="col-sm-6 form-group">
<input type="text" id="lastname" class="register-input" name="lastname" placeholder="Last Name*" required>
</div>
<div class="col-sm-6 form-group">
<input type="text" id="phone" class="register-input" name="phone" placeholder="(___) ___-____" minlength="10" maxlength="10" required>
</div>
<div class="col-sm-6 form-group">
<input type="email" id="email" class="register-input" name="email" placeholder="Email Adress*" required>
</div>
<div class="col-sm-12 form-group">
<input type="date" id="dateofbirth" class="register-input" name="dateofbirth" placeholder="Date of Birth" required>
</div>
</div>
<!------------------------------------------------>
<!-- Address -->
<!------------------------------------------------>
<div class="row">
<div class="col-sm-12">
<h4 class="text-left"> Address</h4>
</div>
<div class="col-sm-12 form-group">
<input type="text" id="address" class="register-input form-control" name="address" placeholder="Street Address" required>
</div>
<div class="col-md-4 form-group">
<input type="text" id="zipCode" class="register-input form-control" name="zipCode" placeholder="Zipcode" value="<?php echo $_POST["zipCode"]; ?>">
</div>
<div class="col-md-4 form-group">
<input type="text" id="city" class="register-input form-control city" name="city" placeholder="City" value="<?php echo $_POST["city"]; ?>" readonly required>
</div>
<div class="col-md-4 form-group">
<input type="text" id="state" class="register-input form-control state" name="state" placeholder="State" value="<?php echo $_POST["state"]; ?>" readonly required>
</div>
</div>
<!------ ROW END ------>
<input value="Submit" id="submitButton" sid="datepicker" class="register-submit" type="submit">
</form>
<!--end register form -->
<p class="register-form-terms">THIS IS NOT HEALTH INSURANCE</p>
</div>
<!--end form-->
</div>
<!--end register-form-wrapper-->
</div>
<!--end col-md-8-->
</div>
<!--end row-->
</div>
<!--end container-->
</section>
<script>
function submitForm()
{
$('#submitButton').prop('disabled', true);
$.ajax({
type: 'post',
dataType:'jsonp',
url: 'https://ushaleads.healthinsuranceguide.org/api/LeadAPI',
data: $('form').serialize(),
success: function () {
console.log('success');
window.location.href = "form-success.html";
},
error:function(){
console.log('Error');
window.location.href = "form-success.html";
}
})
};
$(document).ready(function(){
$('input:checkbox').click(function() {
$('input:checkbox').not(this).prop('checked', false);
});
});
/*-----------------------------------------------------------------------*/
/*----------------------- Phone Number Input Mask -----------------------*/
/*-----------------------------------------------------------------------*/
$(document).ready(function(){
$('#phone').mask('0000000000');
});
/*-----------------------------------------------------------------------*/
/*---------------------------- Zip Code Lookup --------------------------*/
/*-----------------------------------------------------------------------*/
$('#zipCode').on("input",function(){
var zipCode = $('#zipCode').val();
if(zipCode.length == 5)
{
$.ajax({
type: 'GET',
url:'https://ziplookup.visualyzers.com/Ziplookup?zipcode=' + zipCode,
success:function(results){
$('#city').val(results.city);
$('#state').val(results.state);
}
})
}
});
/*-------------------------------------------------------------------------*/
/*---------------------------- Validation Lookup --------------------------*/
/*-------------------------------------------------------------------------*/
$("#valForm").submit(function(e) {
e.preventDefault();
}).validate({
rules:{
phone:{
required:true,
minlength:10,
maxlength:10
},
firstname:{
required:true
},
lastname:{
required:true
},
dateofbirth:{
required:true,
date:true,
},
typeofplan:{
required: true
},
email:{
required:true,
email:true
},
city:{
required:true
},
state:{
required:true
},
zipCode:{
required:true,
minlength:5,
maxlength:5
}
},
messages: {
phone: {
required: "Please enter a valid phone number"
},
},
submitHandler: function(event)
{
submitForm();
}
});
$(function() {
$( "#datepicker" ).datepicker({
dateFormat : 'mm/dd/yy',
changeMonth : true,
changeYear : true,
yearRange: '-100y:c+nn',
maxDate: '-1d'
});
});
</script>
<?php include("footer.php"); ?>