{"id":5314,"date":"2026-05-17T17:14:04","date_gmt":"2026-05-17T17:14:04","guid":{"rendered":"https:\/\/myvidamed.org\/?page_id=5314"},"modified":"2026-05-17T17:14:05","modified_gmt":"2026-05-17T17:14:05","slug":"form-1","status":"publish","type":"page","link":"https:\/\/myvidamed.com\/en\/form-1\/","title":{"rendered":"form 1"},"content":{"rendered":"<style>\n\/* Textarea Styling *\/\n#gohighlvel-multistep textarea {\n    width: 100% !important;\n    min-height: 160px !important;\n    padding: 18px 20px !important;\n    border: 1.5px solid #d9d9d9 !important;\n    border-radius: 16px !important;\n    font-size: 18px !important;\n    line-height: 1.5 !important;\n    font-family: inherit !important;\n    background: #fff !important;\n    color: #001c4c !important;\n    resize: vertical !important;\n    transition: all 0.3s ease !important;\n    outline: none !important;\n    box-sizing: border-box !important;\n}\n\n\/* Placeholder *\/\n#gohighlvel-multistep textarea::placeholder {\n    color: #9b9b9b !important;\n    font-weight: 500 !important;\n}\n\n\/* Focus State *\/\n#gohighlvel-multistep textarea:focus {\n    border-color: #6fcf97 !important;\n    box-shadow: 0 0 0 4px rgba(111, 207, 151, 0.15) !important;\n}\n\n\/* Mobile *\/\n@media (max-width: 767px) {\n    #gohighlvel-multistep textarea {\n        min-height: 140px !important;\n        font-size: 16px !important;\n        padding: 16px !important;\n    }\n}\n\/* Standard spacing between form options *\/\n#gohighlvel-multistep .glp-option {\n    margin-bottom: 16px !important;\n}\n\n\/* Remove extra space from last option *\/\n#gohighlvel-multistep .glp-option:last-child {\n    margin-bottom: 0 !important;\n}\n\n\/* Better section spacing *\/\n#gohighlvel-multistep .glp-question {\n    margin-bottom: 14px !important;\n}\n\n#gohighlvel-multistep .glp-checkbox-group,\n#gohighlvel-multistep .glp-radio-group {\n    margin-bottom: 32px !important;\n}\n\n\/* Heading spacing *\/\n#gohighlvel-multistep .glp-title {\n    margin-bottom: 12px !important;\n}\n\n#gohighlvel-multistep .glp-subtitle {\n    margin-bottom: 24px !important;\n    line-height: 1.5;\n}\n#gohighlvel-multistep .glp-step[data-step=\"1\"].active {\n    display:block !important;\n}\n.glp-progress-wrapper {\n    display: flex;\n    align-items: center;\n    justify-content: space-between;\n    gap: 12px;\n    background: #f7f7f7;\n    padding: 28px 22px;\n    border-radius: 8px;\n    flex-wrap: wrap;\n    font-family: sans-serif;\n}\n\n.glp-progress-step {\n    display: flex;\n    align-items: center;\n    gap: 10px;\n    color: #8e8e8e;\n    font-size: 18px;\n    font-weight: 600;\n    white-space: nowrap;\n    text-t\n}\n\n.glp-progress-step .glp-circle {\n    width: 22px;\n    height: 22px;\n    border-radius: 50%;\n    background: #d9d9d9;\n    display: flex;\n    align-items: center;\n    justify-content: center;\n    font-size: 14px;\n    color: #1d1d1d;\n    flex-shrink: 0;\n}\n\n.glp-progress-step.completed {\n    color: #1d1d1d;\n}\n\n.glp-progress-step.completed .glp-circle {\n    background: #c8f1df;\n    font-weight: bold;\n}\n\n.glp-progress-step.active {\n    color: #1d1d1d;\n}\n\n.glp-progress-step.active .glp-circle {\n    background: #bff1d7;\n}\n\n.glp-line {\n    flex: 1;\n    height: 2px;\n    background: #cfcfcf;\n    min-width: 15px;\n}\n\n.glp-line.active {\n    background: #333;\n}\n.col-12 {\n    width: 100%;\n}\n\/* Mobile *\/\n@media (max-width: 768px) {\n    .glp-progress-wrapper {\n        gap: 3px;\n        padding: 10px 15px;\n    }\n\n    .glp-progress-step {\n        font-size: 10px;\n        gap:5px;\n    }\n\n    .glp-progress-step .glp-circle {\n        width: 10px;\n        height: 10px;\n        font-size: 10px;\n    }\n\n    .glp-line {\n        min-width: 20px;\n        display:none;\n    }\n}\n\n\n    <\/style>\n\n\n<div id=\"glp-form\">\n\n<form id=\"gohighlvel-multistep\" method=\"post\" enctype=\"multipart\/form-data\" novalidate>\n    <input type=\"hidden\" name=\"action\" value=\"glp_gohighlvel_form\">\n\n<div class=\"glp-step active\" data-step=\"1\">\n  <!--  <h5 class=\"glp-stage\">\n        STAGE 1: START    <\/h5>-->\n\n    <p class=\"glp-small-text\">\n        Not sure which medication to choose?    <\/p>\n\n    <p class=\"glp-desc\">\n        Answer these questions to find the right one for you.    <\/p>\n\n    \n    <h2 class=\"glp-title\">\n        Ready to Transform?    <\/h2>\n\n    <p class=\"glp-subtitle\">\n        Let's start with your name and email to personalize your care and save your progress.    <\/p>\n\n    <div class=\"glp-row\">\n\n        <div class=\"col-6 mb-3 relative\">\n            <label>Email*<\/label>\n            <input type=\"email\" name=\"email\" required autocomplete=\"email\">\n        <\/div>\n\n    <\/div>\n\n    <div class=\"glp-row\">\n\n        <div class=\"col-6 mb-3 relative\">\n            <label>First name*<\/label>\n            <input type=\"text\" name=\"first_name\" required autocomplete=\"off\">\n        <\/div>\n\n    <\/div>\n\n    <div class=\"glp-row\">\n\n        <div class=\"col-6 mb-3 relative\">\n            <label>Last Name*<\/label>\n            <input type=\"text\" name=\"last_name\" required autocomplete=\"off\">\n        <\/div>\n\n    <\/div>\n\n    <button type=\"button\" class=\"glp-next-btn\">\n        Continue    <\/button>\n\n<\/div>\n\n<!-- STEP 2 -->\n<div class=\"glp-step\" data-step=\"2\">\n    <!-- <h5 class=\"glp-stage\">\n        STAGE 2: PRELIMINARY    <\/h5>-->\n    <h2 class=\"glp-title\">\n        Reach your ideal weight without impossible diets.    <\/h2>\n\n    <p class=\"glp-subtitle\">\n        What is your height and weight?    <\/p>\n\n    <div class=\"glp-row glp-height-row\">\n\n        <div class=\"col-12\">\n\n            <label>\n                Height            <\/label>\n\n            <div class=\"glp-height-fields\">\n\n                <select class=\"glp-select\" name=\"height_feet\" required>\n                    <option value=\"\">\n                        Feet                    <\/option>\n\n                                            <option value=\"4\">\n                            4                        <\/option>\n                                            <option value=\"5\">\n                            5                        <\/option>\n                                            <option value=\"6\">\n                            6                        <\/option>\n                                            <option value=\"7\">\n                            7                        <\/option>\n                    \n                <\/select>\n\n                <select class=\"glp-select\" name=\"height_inches\" required>\n\n                    <option value=\"\">\n                        Inches                    <\/option>\n\n                                            <option value=\"0\">\n                            0                        <\/option>\n                                            <option value=\"1\">\n                            1                        <\/option>\n                                            <option value=\"2\">\n                            2                        <\/option>\n                                            <option value=\"3\">\n                            3                        <\/option>\n                                            <option value=\"4\">\n                            4                        <\/option>\n                                            <option value=\"5\">\n                            5                        <\/option>\n                                            <option value=\"6\">\n                            6                        <\/option>\n                                            <option value=\"7\">\n                            7                        <\/option>\n                                            <option value=\"8\">\n                            8                        <\/option>\n                                            <option value=\"9\">\n                            9                        <\/option>\n                                            <option value=\"10\">\n                            10                        <\/option>\n                                            <option value=\"11\">\n                            11                        <\/option>\n                    \n                <\/select>\n\n            <\/div>\n\n        <\/div>\n\n        <div class=\"col-12\">\n\n            <label>\n                Weight in lbs            <\/label>\n\n            <input\n                required\n                type=\"number\"\n                name=\"weight\"\n                placeholder=\"Enter weight\">\n\n        <\/div>\n\n    <\/div>\n\n    <div class=\"glp-bmi-box\">\n\n        <strong>\n            Perfect! With a BMI of            <span class=\"glp-bmi\">[X]<\/span>,\n            we can continue.        <\/strong>\n\n        <p>\n            We're in this together. Your goal is our goal.        <\/p>\n\n    <\/div>\n        <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-row\">\n\n        <div class=\"col-12\">\n\n            <label>\n                What is your ideal weight?            <\/label>\n\n            <input\n            required\n                type=\"number\"\n                name=\"ideal_weight\"\n                placeholder=\"Enter ideal weight\">\n\n        <\/div>\n\n    <\/div>\n       <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Are you male or female?        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"gender\" value=\"Male\" required>\n            <span>Male<\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"gender\" value=\"Female\">\n            <span>Female<\/span>\n        <\/label>\n\n    <\/div>\n\n        <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                        <\/div>\n                    <div class=\"glp-step\">\n                        \n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Safety, first.        <\/label>\n\n        <p class=\"glp-small-text\">\n            Do any of these apply to you?        <\/p>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"pregnancy\" value=\"Currently pregnant\" required>\n            <span>\n                Currently or possibly pregnant, or actively trying to become pregnant            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"pregnancy\" value=\"Breastfeeding\" >\n            <span>\n                Breastfeeding or bottle-feeding with breastmilk            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"pregnancy\" value=\"Given birth\">\n            <span>\n                Have given birth to a child within the last 6 months            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"pregnancy\" value=\"None\">\n            <span>\n                None of the above            <\/span>\n        <\/label>\n\n    <\/div>\n\n      <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n\n                        <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Improving your life requires motivation.        <\/label>\n\n        <p class=\"glp-small-text\">\n            What is your primary reason for looking into GLP-1 medication?        <\/p>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"reason\" value=\"Live longer\" required>\n            <span>\n                I want to live longer            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"reason\" value=\"Look better\" >\n            <span>\n                I want to feel and look better            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"reason\" value=\"Reduce health issues\">\n            <span>\n                I want to reduce current health issues            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"reason\" value=\"All\">\n            <span>\n                All of these            <\/span>\n        <\/label>\n\n    <\/div>\n\n        <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                        <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            GLP-1s help you lose weight at a pace that works for you        <\/label>\n\n        <p class=\"glp-small-text\">\n            How quickly are you hoping to reach your goal?        <\/p>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"speed\" value=\"Slow\" required>\n            <span>\n                I'm fine taking it slow            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"speed\" value=\"Fast\">\n            <span>\n                I'd like to see faster results            <\/span>\n        <\/label>\n\n        <label class=\"glp-option\">\n            <input type=\"radio\" name=\"speed\" value=\"Steady\">\n            <span>\n                I'm in no rush \u2014 steady is best            <\/span>\n        <\/label>\n\n    <\/div>\n\n    \n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n\n<\/div>\n<!-- STEP 3 -->\n<div class=\"glp-step\" data-step=\"3\">\n    \n<!--<h5 class=\"glp-stage\">\n        STAGE 3: HEALTH    <\/h5> -->\n    <h2 class=\"glp-title\">\n        GLP-1 is safe, but these health conditions might prevent you from being prescribed.    <\/h2>\n\n    <p class=\"glp-subtitle\">\n        Your answers are completely confidential and protected by HIPAA.    <\/p>\n\n    <div class=\"glp-checkbox-group\">\n\n        <label class=\"glp-question\">\n            Do you have any of the following conditions? (select all that apply)        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"High blood pressure\">\n\n                <span>High blood pressure<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"High cholesterol\">\n\n                <span>High cholesterol<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"Diabetes\">\n\n                <span>Diabetes<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"Heart disease\">\n\n                <span>Heart disease<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"Thyroid issues\">\n\n                <span>Thyroid issues<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"None of the above\">\n\n                <span>None of the above<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                    required\n                    type=\"checkbox\"\n                    name=\"conditions_primary[]\"\n                    value=\"I&#039;m not sure\">\n\n                <span>I&#039;m not sure<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n      <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-checkbox-group\">\n\n        <label class=\"glp-question\">\n            A few more health questions        <\/label>\n\n        <p class=\"glp-small-text\">\n            Do you have any of the following conditions? (select all that apply)        <\/p>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"conditions_secondary[]\"\n                    value=\"Kidney disease\">\n\n                <span>Kidney disease<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"conditions_secondary[]\"\n                    value=\"Liver disease\">\n\n                <span>Liver disease<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"conditions_secondary[]\"\n                    value=\"Cancer\">\n\n                <span>Cancer<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"conditions_secondary[]\"\n                    value=\"Autoimmune disorder\">\n\n                <span>Autoimmune disorder<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"conditions_secondary[]\"\n                    value=\"None of the above\">\n\n                <span>None of the above<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"conditions_secondary[]\"\n                    value=\"I&#039;m not sure\">\n\n                <span>I&#039;m not sure<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n      <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Have you taken medication for weight loss within the past 4 weeks?*\n        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_loss_medication\"\n                    value=\"Yes, I&#039;ve taken GLP-1 medication\">\n\n                <span>Yes, I&#039;ve taken GLP-1 medication<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_loss_medication\"\n                    value=\"Yes, I&#039;ve taken a different medication for weight loss\">\n\n                <span>Yes, I&#039;ve taken a different medication for weight loss<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_loss_medication\"\n                    value=\"No\">\n\n                <span>No<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n         <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Have you had prior weight loss surgeries?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_loss_surgery\"\n                    value=\"Yes\">\n\n                <span>Yes<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_loss_surgery\"\n                    value=\"No\">\n\n                <span>No<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n         <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-checkbox-group\">\n\n        <label class=\"glp-question\">\n            If clinically appropriate, are you willing to:        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"willingness[]\"\n                    value=\"Reduce your caloric intake alongside medication\">\n\n                <span>Reduce your caloric intake alongside medication<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"willingness[]\"\n                    value=\"Increase your physical activity alongside medication\">\n\n                <span>Increase your physical activity alongside medication<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"checkbox\"\n                    name=\"willingness[]\"\n                    value=\"None of the above\">\n\n                <span>None of the above<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n        <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Has your weight changed in the last year?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_change\"\n                    value=\"Lost a significant amount\">\n\n                <span>Lost a significant amount<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_change\"\n                    value=\"Lost a little\">\n\n                <span>Lost a little<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_change\"\n                    value=\"About the same\">\n\n                <span>About the same<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_change\"\n                    value=\"Gained a little\">\n\n                <span>Gained a little<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"weight_change\"\n                    value=\"Gained a significant amount\">\n\n                <span>Gained a significant amount<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n        <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-textarea-group\">\n\n        <label class=\"glp-question\">\n            If you have any known allergies, please list them here.        <\/label>\n\n        <textarea\n        \n            name=\"allergies\"\n            rows=\"5\"\n            placeholder=\"Type your allergies here...\"><\/textarea>\n\n    <\/div>\n\n\n    <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n\n<\/div>\n<!-- STEP 4 -->\n<div class=\"glp-step\" data-step=\"4\">\n\n   <!-- <h5 class=\"glp-stage\">\n        STAGE 4: DETAILS    <\/h5> -->\n\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Which of these is most important to you?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"priority\"\n                    value=\"Lowest price\">\n\n                <span>Lowest price<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"priority\"\n                    value=\"Faster results\">\n\n                <span>Faster results<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"priority\"\n                    value=\"Balanced option\">\n\n                <span>Balanced option<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n   <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Format preference        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"format_preference\"\n                    value=\"I prefer to inject\">\n\n                <span>I prefer to inject<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"format_preference\"\n                    value=\"I prefer a tablet\">\n\n                <span>I prefer a tablet<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Do you currently take any medications?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"current_medications\"\n                    value=\"Yes\">\n\n                <span>Yes<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"current_medications\"\n                    value=\"No\">\n\n                <span>No<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n     <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            How motivated are you to reach <span class=\"glp-goal-weight\">[ideal weight]<\/span>?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"motivation\"\n                    value=\"I&#039;m Ready!\">\n\n                <span>I&#039;m Ready!<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"motivation\"\n                    value=\"I&#039;m feeling hopeful\">\n\n                <span>I&#039;m feeling hopeful<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"motivation\"\n                    value=\"I&#039;m cautious\">\n\n                <span>I&#039;m cautious<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n\n\n    <div class=\"glp-info-box\">\n\n        <p>\n            Your responses will be reviewed by a doctor within two business days.        <\/p>\n\n    <\/div>\n\n <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            Do you have any further information which you would like our medical team to know?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                data-ans=\"Yes\"\n                required\n                    type=\"radio\"\n                    name=\"medical_team_info\"\n                    value=\"Yes\"\n                    class=\"glp-medical-info-toggle\">\n\n                <span>Yes<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                data-ans=\"No\"\n                required\n                    type=\"radio\"\n                    name=\"medical_team_info\"\n                    value=\"No\"\n                    class=\"glp-medical-info-toggle\">\n\n                <span>No<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n\n\n    <div class=\"glp-textarea-group glp-medical-info-box\" style=\"display:none;\">\n\n        <textarea\n            name=\"medical_notes\"\n            rows=\"5\"\n            placeholder=\"Please share additional information here...\"><\/textarea>\n\n    <\/div>\n\n\n\n    <div class=\"glp-info-content\">\n\n        <p>\n            Your consultation will be by text or email for convenience and speed.        <\/p>\n\n        <p>\n            If you have special circumstances, you can request a phone or video call with your doctor after completing this form.        <\/p>\n\n        <p>\n            In most cases, the info you've provided on this form will be enough for a doctor to make a decision.        <\/p>\n\n    <\/div>\n\n      <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-radio-group\">\n\n        <label class=\"glp-question\">\n            What is your preferred language for communicating with our support team and medical doctors?        <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"preferred_language\"\n                    value=\"English\">\n\n                <span>English<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"preferred_language\"\n                    value=\"Spanish\">\n\n                <span>Spanish<\/span>\n\n            <\/label>\n\n        \n            <label class=\"glp-option\">\n\n                <input\n                required\n                    type=\"radio\"\n                    name=\"preferred_language\"\n                    value=\"No preference\">\n\n                <span>No preference<\/span>\n\n            <\/label>\n\n        \n    <\/div>\n\n\n\n <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n<\/div>\n<!-- FINAL STEP -->\n<div class=\"glp-step\" data-step=\"5\">\n <!--   <h5 class=\"glp-stage\">\n        STAGE 5: ELIGIBILITY    <\/h5>-->\n\n    <h2 class=\"glp-title\">\n        What is your date of birth?    <\/h2>\n\n\n    <div class=\"glp-dob-wrap\">\n\n        <label class=\"glp-question\">\n            Date of birth        <\/label>\n\n        <div class=\"glp-row\">\n\n            <div class=\"col-4\">\n\n                <select class=\"glp-select\" name=\"dob_month\" required>\n\n                    <option value=\"\">\n                        Month                    <\/option>\n\n                    \n                        <option value=\"January\">\n                            January                        <\/option>\n\n                    \n                        <option value=\"February\">\n                            February                        <\/option>\n\n                    \n                        <option value=\"March\">\n                            March                        <\/option>\n\n                    \n                        <option value=\"April\">\n                            April                        <\/option>\n\n                    \n                        <option value=\"May\">\n                            May                        <\/option>\n\n                    \n                        <option value=\"June\">\n                            June                        <\/option>\n\n                    \n                        <option value=\"July\">\n                            July                        <\/option>\n\n                    \n                        <option value=\"August\">\n                            August                        <\/option>\n\n                    \n                        <option value=\"September\">\n                            September                        <\/option>\n\n                    \n                        <option value=\"October\">\n                            October                        <\/option>\n\n                    \n                        <option value=\"November\">\n                            November                        <\/option>\n\n                    \n                        <option value=\"December\">\n                            December                        <\/option>\n\n                    \n                <\/select>\n\n            <\/div>\n\n\n            <div class=\"col-4\">\n\n                <select class=\"glp-select\" name=\"dob_day\" required>\n\n                    <option value=\"\">\n                        Day                    <\/option>\n\n                    \n                        <option value=\"1\">\n                            1                        <\/option>\n\n                    \n                        <option value=\"2\">\n                            2                        <\/option>\n\n                    \n                        <option value=\"3\">\n                            3                        <\/option>\n\n                    \n                        <option value=\"4\">\n                            4                        <\/option>\n\n                    \n                        <option value=\"5\">\n                            5                        <\/option>\n\n                    \n                        <option value=\"6\">\n                            6                        <\/option>\n\n                    \n                        <option value=\"7\">\n                            7                        <\/option>\n\n                    \n                        <option value=\"8\">\n                            8                        <\/option>\n\n                    \n                        <option value=\"9\">\n                            9                        <\/option>\n\n                    \n                        <option value=\"10\">\n                            10                        <\/option>\n\n                    \n                        <option value=\"11\">\n                            11                        <\/option>\n\n                    \n                        <option value=\"12\">\n                            12                        <\/option>\n\n                    \n                        <option value=\"13\">\n                            13                        <\/option>\n\n                    \n                        <option value=\"14\">\n                            14                        <\/option>\n\n                    \n                        <option value=\"15\">\n                            15                        <\/option>\n\n                    \n                        <option value=\"16\">\n                            16                        <\/option>\n\n                    \n                        <option value=\"17\">\n                            17                        <\/option>\n\n                    \n                        <option value=\"18\">\n                            18                        <\/option>\n\n                    \n                        <option value=\"19\">\n                            19                        <\/option>\n\n                    \n                        <option value=\"20\">\n                            20                        <\/option>\n\n                    \n                        <option value=\"21\">\n                            21                        <\/option>\n\n                    \n                        <option value=\"22\">\n                            22                        <\/option>\n\n                    \n                        <option value=\"23\">\n                            23                        <\/option>\n\n                    \n                        <option value=\"24\">\n                            24                        <\/option>\n\n                    \n                        <option value=\"25\">\n                            25                        <\/option>\n\n                    \n                        <option value=\"26\">\n                            26                        <\/option>\n\n                    \n                        <option value=\"27\">\n                            27                        <\/option>\n\n                    \n                        <option value=\"28\">\n                            28                        <\/option>\n\n                    \n                        <option value=\"29\">\n                            29                        <\/option>\n\n                    \n                        <option value=\"30\">\n                            30                        <\/option>\n\n                    \n                        <option value=\"31\">\n                            31                        <\/option>\n\n                    \n                <\/select>\n\n            <\/div>\n\n\n            <div class=\"col-4\">\n\n                <select class=\"glp-select\" name=\"dob_year\" required>\n\n                    <option value=\"\">\n                        Year                    <\/option>\n\n                    \n                        <option value=\"2026\">\n                            2026                        <\/option>\n\n                    \n                        <option value=\"2025\">\n                            2025                        <\/option>\n\n                    \n                        <option value=\"2024\">\n                            2024                        <\/option>\n\n                    \n                        <option value=\"2023\">\n                            2023                        <\/option>\n\n                    \n                        <option value=\"2022\">\n                            2022                        <\/option>\n\n                    \n                        <option value=\"2021\">\n                            2021                        <\/option>\n\n                    \n                        <option value=\"2020\">\n                            2020                        <\/option>\n\n                    \n                        <option value=\"2019\">\n                            2019                        <\/option>\n\n                    \n                        <option value=\"2018\">\n                            2018                        <\/option>\n\n                    \n                        <option value=\"2017\">\n                            2017                        <\/option>\n\n                    \n                        <option value=\"2016\">\n                            2016                        <\/option>\n\n                    \n                        <option value=\"2015\">\n                            2015                        <\/option>\n\n                    \n                        <option value=\"2014\">\n                            2014                        <\/option>\n\n                    \n                        <option value=\"2013\">\n                            2013                        <\/option>\n\n                    \n                        <option value=\"2012\">\n                            2012                        <\/option>\n\n                    \n                        <option value=\"2011\">\n                            2011                        <\/option>\n\n                    \n                        <option value=\"2010\">\n                            2010                        <\/option>\n\n                    \n                        <option value=\"2009\">\n                            2009                        <\/option>\n\n                    \n                        <option value=\"2008\">\n                            2008                        <\/option>\n\n                    \n                        <option value=\"2007\">\n                            2007                        <\/option>\n\n                    \n                        <option value=\"2006\">\n                            2006                        <\/option>\n\n                    \n                        <option value=\"2005\">\n                            2005                        <\/option>\n\n                    \n                        <option value=\"2004\">\n                            2004                        <\/option>\n\n                    \n                        <option value=\"2003\">\n                            2003                        <\/option>\n\n                    \n                        <option value=\"2002\">\n                            2002                        <\/option>\n\n                    \n                        <option value=\"2001\">\n                            2001                        <\/option>\n\n                    \n                        <option value=\"2000\">\n                            2000                        <\/option>\n\n                    \n                        <option value=\"1999\">\n                            1999                        <\/option>\n\n                    \n                        <option value=\"1998\">\n                            1998                        <\/option>\n\n                    \n                        <option value=\"1997\">\n                            1997                        <\/option>\n\n                    \n                        <option value=\"1996\">\n                            1996                        <\/option>\n\n                    \n                        <option value=\"1995\">\n                            1995                        <\/option>\n\n                    \n                        <option value=\"1994\">\n                            1994                        <\/option>\n\n                    \n                        <option value=\"1993\">\n                            1993                        <\/option>\n\n                    \n                        <option value=\"1992\">\n                            1992                        <\/option>\n\n                    \n                        <option value=\"1991\">\n                            1991                        <\/option>\n\n                    \n                        <option value=\"1990\">\n                            1990                        <\/option>\n\n                    \n                        <option value=\"1989\">\n                            1989                        <\/option>\n\n                    \n                        <option value=\"1988\">\n                            1988                        <\/option>\n\n                    \n                        <option value=\"1987\">\n                            1987                        <\/option>\n\n                    \n                        <option value=\"1986\">\n                            1986                        <\/option>\n\n                    \n                        <option value=\"1985\">\n                            1985                        <\/option>\n\n                    \n                        <option value=\"1984\">\n                            1984                        <\/option>\n\n                    \n                        <option value=\"1983\">\n                            1983                        <\/option>\n\n                    \n                        <option value=\"1982\">\n                            1982                        <\/option>\n\n                    \n                        <option value=\"1981\">\n                            1981                        <\/option>\n\n                    \n                        <option value=\"1980\">\n                            1980                        <\/option>\n\n                    \n                        <option value=\"1979\">\n                            1979                        <\/option>\n\n                    \n                        <option value=\"1978\">\n                            1978                        <\/option>\n\n                    \n                        <option value=\"1977\">\n                            1977                        <\/option>\n\n                    \n                        <option value=\"1976\">\n                            1976                        <\/option>\n\n                    \n                        <option value=\"1975\">\n                            1975                        <\/option>\n\n                    \n                        <option value=\"1974\">\n                            1974                        <\/option>\n\n                    \n                        <option value=\"1973\">\n                            1973                        <\/option>\n\n                    \n                        <option value=\"1972\">\n                            1972                        <\/option>\n\n                    \n                        <option value=\"1971\">\n                            1971                        <\/option>\n\n                    \n                        <option value=\"1970\">\n                            1970                        <\/option>\n\n                    \n                        <option value=\"1969\">\n                            1969                        <\/option>\n\n                    \n                        <option value=\"1968\">\n                            1968                        <\/option>\n\n                    \n                        <option value=\"1967\">\n                            1967                        <\/option>\n\n                    \n                        <option value=\"1966\">\n                            1966                        <\/option>\n\n                    \n                        <option value=\"1965\">\n                            1965                        <\/option>\n\n                    \n                        <option value=\"1964\">\n                            1964                        <\/option>\n\n                    \n                        <option value=\"1963\">\n                            1963                        <\/option>\n\n                    \n                        <option value=\"1962\">\n                            1962                        <\/option>\n\n                    \n                        <option value=\"1961\">\n                            1961                        <\/option>\n\n                    \n                        <option value=\"1960\">\n                            1960                        <\/option>\n\n                    \n                        <option value=\"1959\">\n                            1959                        <\/option>\n\n                    \n                        <option value=\"1958\">\n                            1958                        <\/option>\n\n                    \n                        <option value=\"1957\">\n                            1957                        <\/option>\n\n                    \n                        <option value=\"1956\">\n                            1956                        <\/option>\n\n                    \n                        <option value=\"1955\">\n                            1955                        <\/option>\n\n                    \n                        <option value=\"1954\">\n                            1954                        <\/option>\n\n                    \n                        <option value=\"1953\">\n                            1953                        <\/option>\n\n                    \n                        <option value=\"1952\">\n                            1952                        <\/option>\n\n                    \n                        <option value=\"1951\">\n                            1951                        <\/option>\n\n                    \n                        <option value=\"1950\">\n                            1950                        <\/option>\n\n                    \n                        <option value=\"1949\">\n                            1949                        <\/option>\n\n                    \n                        <option value=\"1948\">\n                            1948                        <\/option>\n\n                    \n                        <option value=\"1947\">\n                            1947                        <\/option>\n\n                    \n                        <option value=\"1946\">\n                            1946                        <\/option>\n\n                    \n                        <option value=\"1945\">\n                            1945                        <\/option>\n\n                    \n                        <option value=\"1944\">\n                            1944                        <\/option>\n\n                    \n                        <option value=\"1943\">\n                            1943                        <\/option>\n\n                    \n                        <option value=\"1942\">\n                            1942                        <\/option>\n\n                    \n                        <option value=\"1941\">\n                            1941                        <\/option>\n\n                    \n                        <option value=\"1940\">\n                            1940                        <\/option>\n\n                    \n                <\/select>\n\n            <\/div>\n\n        <\/div>\n\n    <\/div>\n <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-review-box\">\n\n        <h3>\n            Your Medical Review        <\/h3>\n\n        <p>\n            <strong>BMI:<\/strong>\n            <span class=\"glp-bmi-value\">[X]<\/span>\n\n            &nbsp;&nbsp;\n\n            <strong>Current:<\/strong>\n            <span class=\"glp-current-weight\">[X]<\/span> lbs\n\n            &nbsp;&nbsp;\n\n            <strong>Goal Weight:<\/strong>\n            <span class=\"glp-goal-weight\">[X]<\/span> lbs\n        <\/p>\n\n    <\/div>\n\n      <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-info-content\">\n\n        <h3>\n            Your transformation is closer than you think!        <\/h3>\n\n        <p>\n            Let's proceed to check your eligibility.        <\/p>\n\n    <\/div>\n\n\n\n    <div class=\"glp-state-wrap\">\n\n        <label class=\"glp-question\">\n            What state will your medication be shipped to?        <\/label>\n\n        <select class=\"glp-select\" name=\"shipping_state\" required>\n\n            <option value=\"\">\n                Select State            <\/option>\n\n            \n                <option value=\"Alabama\">\n                    Alabama                <\/option>\n\n            \n                <option value=\"Alaska\">\n                    Alaska                <\/option>\n\n            \n                <option value=\"Arizona\">\n                    Arizona                <\/option>\n\n            \n                <option value=\"Arkansas\">\n                    Arkansas                <\/option>\n\n            \n                <option value=\"California\">\n                    California                <\/option>\n\n            \n                <option value=\"Colorado\">\n                    Colorado                <\/option>\n\n            \n                <option value=\"Connecticut\">\n                    Connecticut                <\/option>\n\n            \n                <option value=\"Delaware\">\n                    Delaware                <\/option>\n\n            \n                <option value=\"Florida\">\n                    Florida                <\/option>\n\n            \n                <option value=\"Georgia\">\n                    Georgia                <\/option>\n\n            \n                <option value=\"Hawaii\">\n                    Hawaii                <\/option>\n\n            \n                <option value=\"Idaho\">\n                    Idaho                <\/option>\n\n            \n                <option value=\"Illinois\">\n                    Illinois                <\/option>\n\n            \n                <option value=\"Indiana\">\n                    Indiana                <\/option>\n\n            \n                <option value=\"Iowa\">\n                    Iowa                <\/option>\n\n            \n                <option value=\"Kansas\">\n                    Kansas                <\/option>\n\n            \n                <option value=\"Kentucky\">\n                    Kentucky                <\/option>\n\n            \n                <option value=\"Louisiana\">\n                    Louisiana                <\/option>\n\n            \n                <option value=\"Maine\">\n                    Maine                <\/option>\n\n            \n                <option value=\"Maryland\">\n                    Maryland                <\/option>\n\n            \n                <option value=\"Massachusetts\">\n                    Massachusetts                <\/option>\n\n            \n                <option value=\"Michigan\">\n                    Michigan                <\/option>\n\n            \n                <option value=\"Minnesota\">\n                    Minnesota                <\/option>\n\n            \n                <option value=\"Mississippi\">\n                    Mississippi                <\/option>\n\n            \n                <option value=\"Missouri\">\n                    Missouri                <\/option>\n\n            \n                <option value=\"Montana\">\n                    Montana                <\/option>\n\n            \n                <option value=\"Nebraska\">\n                    Nebraska                <\/option>\n\n            \n                <option value=\"Nevada\">\n                    Nevada                <\/option>\n\n            \n                <option value=\"New Hampshire\">\n                    New Hampshire                <\/option>\n\n            \n                <option value=\"New Jersey\">\n                    New Jersey                <\/option>\n\n            \n                <option value=\"New Mexico\">\n                    New Mexico                <\/option>\n\n            \n                <option value=\"New York\">\n                    New York                <\/option>\n\n            \n                <option value=\"North Carolina\">\n                    North Carolina                <\/option>\n\n            \n                <option value=\"North Dakota\">\n                    North Dakota                <\/option>\n\n            \n                <option value=\"Ohio\">\n                    Ohio                <\/option>\n\n            \n                <option value=\"Oklahoma\">\n                    Oklahoma                <\/option>\n\n            \n                <option value=\"Oregon\">\n                    Oregon                <\/option>\n\n            \n                <option value=\"Pennsylvania\">\n                    Pennsylvania                <\/option>\n\n            \n                <option value=\"Rhode Island\">\n                    Rhode Island                <\/option>\n\n            \n                <option value=\"South Carolina\">\n                    South Carolina                <\/option>\n\n            \n                <option value=\"South Dakota\">\n                    South Dakota                <\/option>\n\n            \n                <option value=\"Tennessee\">\n                    Tennessee                <\/option>\n\n            \n                <option value=\"Texas\">\n                    Texas                <\/option>\n\n            \n                <option value=\"Utah\">\n                    Utah                <\/option>\n\n            \n                <option value=\"Vermont\">\n                    Vermont                <\/option>\n\n            \n                <option value=\"Virginia\">\n                    Virginia                <\/option>\n\n            \n                <option value=\"Washington\">\n                    Washington                <\/option>\n\n            \n                <option value=\"West Virginia\">\n                    West Virginia                <\/option>\n\n            \n                <option value=\"Wisconsin\">\n                    Wisconsin                <\/option>\n\n            \n                <option value=\"Wyoming\">\n                    Wyoming                <\/option>\n\n            \n        <\/select>\n\n    <\/div>\n\n      <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-consent-box\">\n\n        <p>\n            Your information is never shared and is protected by HIPAA.        <\/p>\n\n        <label class=\"glp-checkbox-option\">\n\n            <input type=\"checkbox\" name=\"telehealth_consent\" required>\n\n            <span>\n                By checking this box, I consent to receive healthcare services via telehealth. I understand that a licensed provider will review my information remotely and may prescribe treatment if appropriate. I understand the benefits and risks\/limitations of telehealth care, and that all communications and records are securely handled in compliance with HIPAA and the Consent to Telehealth terms.            <\/span>\n\n        <\/label>\n\n    <\/div>\n\n         <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n\n    <div class=\"glp-consent-box\">\n\n        <label class=\"glp-checkbox-option\">\n\n            <input type=\"checkbox\" name=\"telehealth_acknowledgement\" required>\n\n            <span>\n                By checking this box, I acknowledge that I have read and understand the Consent to Telehealth, and I agree to receive care via telehealth.            <\/span>\n\n        <\/label>\n\n    <\/div>\n <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n    <div class=\"glp-contact-section\">\n\n        <h3>\n            <span class=\"glp-user-name\">[NAME]<\/span> how can you be reached if necessary?        <\/h3>\n\n        <p>\n            Our medical team uses email and text for patient communication, as well as updates about programs and services.        <\/p>\n\n    <\/div>\n\n\n\n    <div class=\"glp-phone-wrap\">\n\n        <label class=\"glp-question\">\n            Phone number        <\/label>\n\n        <input\n            type=\"text\"\n            name=\"contact_phone\"\n            class=\"us-phone\"\n            value=\"+1 (___) ___ - ____\"\n            mask=\"+1 (___) ___ - ____\"\n            placeholder=\"+1 (___) ___ - ____\"\n            required>\n\n    <\/div>\n        <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n        <button type=\"button\" class=\"glp-next-btn\">Continue<\/button>\n    <\/div>\n\n                    <\/div>\n                    <div class=\"glp-step\">\n\n\n\n    <div class=\"glp-consent-box\">\n\n        <label class=\"glp-checkbox-option\">\n\n            <input type=\"checkbox\" name=\"sms_consent\" required>\n\n            <span>\n                I agree to receive SMS\/text messages from Vidamed at the number provided. Messages may include reminders, account updates, and promotional offers. Message frequency varies. Message & data rates may apply. Reply STOP to opt out, HELP for help.            <\/span>\n\n        <\/label>\n\n    <\/div>\n\n <div class=\"glp-navigation\">\n        <button type=\"button\" class=\"prev\">Back<\/button>\n\n    <button type=\"submit\" class=\"glp-submit-btn\">\n        Submit    <\/button>\n\n    <\/div>\n\n\n<\/div>\n\n\n<\/form>\n<\/div>\n<style>\n    \/* =========================\n   GLP MULTISTEP FORM UI\n========================= *\/\n\n\n\n\/* Steps *\/\n.glp-step {\n    display: none;\n}\n\n.glp-step.active {\n    display: block;\n}\n\n\/* Typography *\/\n.glp-stage {\n    font-size: 13px;\n    letter-spacing: 1px;\n    color: #00a6a6;\n    margin-bottom: 12px;\n    font-weight: 700;\n    text-transform: uppercase;\n}\n\n#gohighlvel-multistep .glp-title {\n    font-size: 38px;\n    line-height: 1.2;\n    font-weight: 700;\n    color: #111;\n    margin-bottom: 14px;\n}\n\n#gohighlvel-multistep .glp-subtitle,\n#gohighlvel-multistep .glp-desc,\n#gohighlvel-multistep .glp-small-text {\n    font-size: 16px;\n    color: #666;\n    line-height: 1.7;\n\n}\n\n\/* Grid *\/\n#gohighlvel-multistep .glp-row {\n    display: flex;\n    gap: 20px;\n    flex-wrap: wrap;\n}\n\n.col-6 {\n    width: calc(50% - 10px);\n}\n\n.col-4 {\n    width: calc(33.333% - 14px);\n}\n\n\/* Inputs *\/\n#gohighlvel-multistep input,\n#gohighlvel-multistep select,\n#gohighlvel-multistep textarea {\n    width: 100%;\n    padding: 15px 18px;\n    border: 1px solid #ddd;\n    border-radius: 14px;\n    font-size: 15px;\n    background: #fff;\n    transition: all .25s ease;\n    box-sizing: border-box;\n}\n\n#gohighlvel-multistep input:focus,\n#gohighlvel-multistep select:focus,\n#gohighlvel-multistep textarea:focus {\n    outline: none;\n    border-color: #00b8b8;\n    box-shadow: 0 0 0 4px rgba(0,184,184,0.12);\n}\n\n\/* Labels *\/\n#gohighlvel-multistep label {\n    display: block;\n    font-size: 14px;\n    font-weight: 600;\n    margin-bottom: 10px;\n    color: #222;\n}\n\n\/* Radio + Checkbox Cards *\/\n#gohighlvel-multistep .glp-option {\n    display: flex !important;\n    align-items: flex-start;\n    gap: 14px;\n    padding: 16px 18px;\n    border: 1px solid #e5e5e5;\n    border-radius: 16px;\n    margin-bottom: 14px;\n    cursor: pointer;\n    transition: all .25s ease;\n    background: #fff;\n}\n\n#gohighlvel-multistep .glp-option:hover {\n    border-color: #00b8b8;\n    background: #f5ffff;\n}\n\n.glp-option input {\n    width: 18px !important;\n    height: 18px;\n    margin-top: 2px;\n    accent-color: #00b8b8;\n}\n\n.glp-option span {\n    flex: 1;\n    font-size: 15px;\n    line-height: 1.5;\n    color: #333;\n}\n\n\/* Question Headings *\/\n.glp-question {\n    font-size: 20px !important;\n    font-weight: 700 !important;\n    margin-bottom: 18px !important;\n    color: #111;\n}\n\n\/* Buttons *\/\n\n\n\n\/* Info Boxes *\/\n.glp-bmi-box,\n.glp-info-box,\n.glp-review-box,\n.glp-consent-box,\n.glp-info-content {\n    background: #f8fbfb;\n    border: 1px solid #e2f3f3;\n    border-radius: 18px;\n    padding: 20px;\n    margin: 25px 0;\n}\n\n.glp-review-box h3,\n.glp-info-content h3 {\n    margin-top: 0;\n    margin-bottom: 12px;\n}\n\n\/* Height Fields *\/\n.glp-height-fields {\n    display: flex;\n    gap: 12px;\n}\n\n\/* Textareas *\/\n#gohighlvel-multistep textarea {\n    min-height: 120px;\n    resize: vertical;\n}\n\n\/* Checkbox Consent *\/\n.glp-checkbox-option {\n    display: flex !important;\n    align-items: flex-start;\n    gap: 12px;\n}\n\n.glp-checkbox-option input {\n    width: 18px !important;\n    height: 18px;\n    margin-top: 4px;\n}\n\n\/* Mobile *\/\n@media (max-width: 768px) {\n\n    #gohighlvel-multistep {\n        width: 94%;\n        padding: 10px 10px;\n        border-radius: 18px;\n    }\n\n    .glp-title {\n        font-size: 28px;\n    }\n\n    .glp-question {\n        font-size: 18px !important;\n    }\n\n    .col-6,\n    .col-4 {\n        width: 100%;\n    }\n\n    .glp-row {\n        gap: 16px;\n    }\n\n    .glp-option {\n        padding: 14px;\n    }\n\n    .glp-next-btn,\n    .glp-submit-btn {\n        padding: 15px 18px;\n        font-size: 15px;\n    }\n}\n\n\/* Left Intro Text *\/\n.glp-step[data-step=\"1\"] .glp-small-text,\n.glp-step[data-step=\"1\"] .glp-title,\n.glp-step[data-step=\"1\"] .glp-subtitle {\n   text-align:center;\n}\n\n\/* Form Fields Right Side *\/\n.glp-step[data-step=\"1\"] .glp-row,\n.glp-step[data-step=\"1\"] .glp-next-btn {\n    grid-column: 2;\n}\n\n\/* Make all fields full width *\/\n.glp-step[data-step=\"1\"] .col-6 {\n    width: 100%;\n}\n\n\/* Input Styling *\/\n.glp-step[data-step=\"1\"] input {\n    border: 0;\n    border-bottom: 2px solid #18235c;\n    border-radius: 0;\n    padding: 12px 0;\n    background: transparent;\n    font-size: 18px;\n}\n\n.glp-step[data-step=\"1\"] input:focus {\n    outline: none;\n    border-color: #41b6b6;\n    box-shadow: none;\n}\n\n\/* Labels *\/\n.glp-step[data-step=\"1\"] label {\n    font-size: 18px;\n    font-weight: 500;\n    color: #000;\n    margin-bottom: 10px;\n}\n\n\/* Title *\/\n.glp-step[data-step=\"1\"] .glp-title {\n    font-size: 64px;\n    line-height: 1.05;\n    font-weight: 700;\n    color: #14205c;\n    margin: 20px 0 40px;\n}\n\n\/* Subtitle *\/\n.glp-step[data-step=\"1\"] .glp-subtitle,\n.glp-step[data-step=\"1\"] .glp-desc {\n    font-size: 20px;\n    line-height: 1.7;\n    color: #5d6475;\n    text-align:center;\n}\n\n\/* Stage *\/\n.glp-step[data-step=\"1\"] .glp-stage {\n    color: #4ba8a8;\n    font-size: 20px;\n    font-weight: 700;\n    letter-spacing: 1px;\n}\n\n\/* Continue Button *\/\n.glp-step[data-step=\"1\"] .glp-next-btn {\n    width: fit-content;\n    min-width: 220px;\n    margin-top: 30px;\n}\n\n\/* Mobile *\/\n@media (max-width: 768px) {\n\n    .glp-step[data-step=\"1\"].active {\n        grid-template-columns: 1fr;\n        gap: 20px;\n    }\n\n    .glp-step[data-step=\"1\"] .glp-small-text,\n    .glp-step[data-step=\"1\"] .glp-stage,\n    .glp-step[data-step=\"1\"] .glp-title,\n    .glp-step[data-step=\"1\"] .glp-subtitle,\n    .glp-step[data-step=\"1\"] .glp-row,\n    .glp-step[data-step=\"1\"] .glp-next-btn {\n        grid-column: auto;\n    }\n\n    .glp-step[data-step=\"1\"] .glp-title {\n        font-size: 42px;\n    }\n\n    .glp-step[data-step=\"1\"] .glp-subtitle,\n    .glp-step[data-step=\"1\"] .glp-desc {\n        max-width: 100%;\n        font-size: 17px;\n    }\n}\n\/* Error Border Only *\/\n\n.glp-step .error-field,\n#glp-form .glp-select.error-field,\n#glp-form .glp-step label.glp-option.error-field\n{\n    border-bottom: 2px solid red !important;\n}\n\n\/* Radio \/ Checkbox *\/\n.glp-option.error-field {\n    border: 1px solid red !important;\n}\n\/* Hidden by default *\/\n.glp-bmi-box {\n    display: none;\n}\n.glp-success-message{\n    text-align:center;\n    padding:60px 30px;\n    width:100%;\n    box-sizing:border-box;\n}\n\n.glp-success-icon{\n    width:80px;\n    height:80px;\n    margin:0 auto 24px auto;\n    border-radius:50%;\n    background:#6fcf97;\n    color:#ffffff;\n    display:flex;\n    align-items:center;\n    justify-content:center;\n    font-size:40px;\n    font-weight:700;\n    line-height:1;\n}\n\n.glp-success-message h2{\n    font-size:36px;\n    font-weight:700;\n    line-height:1.3;\n    margin:0 0 16px 0;\n    color:#001c4c;\n}\n\n.glp-success-message p{\n    font-size:18px;\n    line-height:1.7;\n    margin:0 0 14px 0;\n    color:#4f4f4f;\n}\n\n.glp-success-user-info{\n    margin-top:30px;\n    padding-top:24px;\n    border-top:1px solid #e5e5e5;\n}\n\n.glp-success-user-info p{\n    font-size:17px;\n    margin-bottom:10px;\n    color:#001c4c;\n}\n\n.glp-success-user-info strong{\n    font-weight:700;\n    color:#000000;\n}\n\n@media (max-width:767px){\n\n    .glp-success-message{\n        padding:40px 20px;\n    }\n\n    .glp-success-icon{\n        width:70px;\n        height:70px;\n        font-size:34px;\n    }\n\n    .glp-success-message h2{\n        font-size:28px;\n    }\n\n    .glp-success-message p{\n        font-size:16px;\n    }\n\n    .glp-success-user-info p{\n        font-size:15px;\n    }\n\n}\n\n<\/style>\n<script>\n    document.addEventListener('DOMContentLoaded', function () {\n   const form = document.querySelector('#gohighlvel-multistep');\n\n    if (form) {\n        form.querySelectorAll('.glp-step').forEach((step, index) => {\n            step.setAttribute('data-progress', index + 1);\n        });\n    }\n    const cssPhone = 'input[name=\"contact_phone\"';\n        console.log(cssPhone);\n        (new phoneMask()).init(cssPhone);\n});\n\n    \njQuery(document).ready(function ($) {\n\n    function getProgressStep(currentStep) {\n\n    \/\/ currentStep = actual form step index\n\n    if (currentStep <= 1) {\n        return 1; \/\/ Step 1\n    }\n\n    if (currentStep <= 7) {\n        return 2; \/\/ Step 2\n    }\n\n    if (currentStep <= 15) {\n        return 3; \/\/ Step 3\n    }\n\n    if (currentStep <= 21) {\n        return 4; \/\/ Step 4\n    }\n\n    return 5; \/\/ Final\n}         \n\n    function updateProgress(currentStep) {\n\n    let progressStep = getProgressStep(currentStep);\n                console.log(currentStep,progressStep,'progressStep');\n    $('.glp-progress-step').removeClass('active completed');\n    $('.glp-line').removeClass('active');\n\n    $('.glp-progress-step').each(function(index) {\n\n        if (index < progressStep) {\n\n            $(this).addClass('completed');\n            $(this).find('.glp-circle').html('\u2713');\n\n            $('.glp-line').eq(index).addClass('active');\n\n        } else if (index === progressStep) {\n\n            $(this).addClass('active');\n            $(this).find('.glp-circle').html('');\n\n        } else {\n\n            $(this).find('.glp-circle').html('');\n        }\n\n    });\n}\n\n    \/*\n    Step Index:\n    0 = Start\n    1 = Preliminary\n    2 = Health\n    3 = Details\n    4 = Eligibility\n    *\/\n\n    \/\/ Example current step\n    updateProgress(1);\n\n$('#gohighlvel-multistep .prev').on('click', function () {\n\n    \/\/ Current Parent Step\n    let currentStepDiv = $(this).closest('.glp-step');\n    let current = $('.glp-progress-step.active').index('.glp-progress-step');\n\n    \/\/ Previous Step\n    let prevStep = currentStepDiv.prev('.glp-step');\n\n    if (prevStep.length) {\n\n        \/\/ Get previous step progress\n        let prevProgress = prevStep.data('progress');\n\n        currentStepDiv.removeClass('active').hide();\n\n        prevStep.addClass('active').fadeIn(function () {\n\n            \/\/ Update Progress\n            updateProgress(prevProgress);\n\n            \/\/ Scroll inside popup body\n            $('.glp-popup-body').animate({\n                scrollTop: prevStep.position().top\n            }, 500);\n\n        });\n    }\n\n});\n\n\n  \n\n\n\n    \/\/ NEXT STEP\n$('.glp-next-btn').on('click', function () {\n\n    \/\/ Current Parent Step\n    let currentStepDiv = $(this).closest('.glp-step');\n    let current = $('.glp-progress-step.active').index('.glp-progress-step');\n\n    \/\/ Get Step Number\n    let step = currentStepDiv.data('step');\n    let progress = currentStepDiv.data('progress');\n\n    \/\/ Validate only current parent\n    if (!validateStep(step, currentStepDiv)) {\n        return;\n    }\n    if (current < $('.glp-progress-step').length - 1) {\n            updateProgress(progress);\n        }\n\n    \/\/ Next Step\n    \/\/ Next Step\n    let nextStep = currentStepDiv.next('.glp-step');\n\n    if (nextStep.length) {\n\n        currentStepDiv.removeClass('active').hide();\n\n        nextStep.addClass('active').fadeIn(function () {\n\n                \/\/ Scroll inside .glp-popup-body instead of page\n            $('.glp-popup-body').animate({\n                scrollTop: nextStep.position().top\n            }, 500);\n\n        });\n    }\n\n});\n\n\nfunction validateStep(step, currentStepDiv) {\n\n    let valid = true;\n\n    \/\/ Remove old error states\n    currentStepDiv.find('.error-field').removeClass('error-field');\n\n    currentStepDiv.find('[required]').each(function () {\n\n        let field = $(this);\n        let value = $.trim(field.val());\n        let type  = field.attr('type');\n        let name  = field.attr('name');\n\n        \/\/ Radio \/ Checkbox\n        if (type === 'radio' || type === 'checkbox') {\n\n            if (!currentStepDiv.find('[name=\"' + name + '\"]:checked').length) {\n\n                valid = false;\n\n                field.closest('.glp-option').addClass('error-field');\n            }\n\n        } else {\n\n            \/\/ Empty validation\n            if (value === '') {\n\n                valid = false;\n\n                field.addClass('error-field');\n\n                return; \/\/ stop further validation for this field\n            }\n\n            \/\/ Email validation\n            if (type === 'email') {\n\n                let emailPattern = \/^[^\\s@]+@[^\\s@]+\\.[^\\s@]+$\/;\n\n                if (!emailPattern.test(value)) {\n\n                    valid = false;\n\n                    field.addClass('error-field');\n                }\n            }\n\n            \/\/ Phone validation\n            if (\n                name === 'contact_phone' ||\n                name === 'phone'\n            ) {\n\n                let cleanPhone = value.replace(\/\\D\/g, '');\n\n                if (cleanPhone.length < 10) {\n\n                    valid = false;\n\n                    field.addClass('error-field');\n                }\n            }\n        }\n\n    });\n\n    return valid;\n}    \n\n    \/\/ Hide BMI box initially\n    $('.glp-bmi-box').hide();\n\n    function calculateBMI() {\n\n        let feet   = parseInt($('[name=\"height_feet\"]').val()) || 0;\n        let inches = parseInt($('[name=\"height_inches\"]').val()) || 0;\n        let weight = parseFloat($('[name=\"weight\"]').val()) || 0;\n\n        \/\/ Total height in inches\n        let totalInches = (feet * 12) + inches;\n\n        \/\/ Check valid values\n        if (totalInches > 0 && weight > 0) {\n\n            \/\/ BMI Formula\n            let bmi = (weight \/ (totalInches * totalInches)) * 703;\n\n            bmi = bmi.toFixed(1);\n\n            \/\/ Update BMI text\n            $('.glp-bmi').text(bmi);\n            $('.glp-bmi-value').text(bmi);\n\n            \/\/ Show box\n            $('.glp-bmi-box').fadeIn();\n\n        } else {\n\n            \/\/ Hide if incomplete\n            $('.glp-bmi-box').fadeOut();\n        }\n    }\n\n    \/\/ Trigger on change\n    $('[name=\"height_feet\"], [name=\"height_inches\"], [name=\"weight\"]')\n        .on('change keyup', function () {\n\n            calculateBMI();\n        });\n\n    $(document).on('change', '.glp-medical-info-toggle', function () {\n\n    let answer = $(this).data('ans');\n\n    if (answer === 'Yes') {\n\n        $('.glp-medical-info-box').slideDown();\n\n        $('.glp-medical-info-box textarea').attr('required', true);\n\n    } else {\n\n        $('.glp-medical-info-box').slideUp();\n\n        $('.glp-medical-info-box textarea').removeAttr('required');\n\n    }\n\n});\nfunction updateWeights() {\n\n        let currentWeight = $('input[name=\"weight\"]').val();\n        let goalWeight    = $('input[name=\"ideal_weight\"]').val();\n\n        $('.glp-current-weight').text(currentWeight ? currentWeight : '[X]');\n        $('.glp-goal-weight').text(goalWeight ? goalWeight : '[X]');\n    }\n\n    \/\/ Update on typing\n    $(document).on('input', 'input[name=\"weight\"], input[name=\"ideal_weight\"]', function () {\n        updateWeights();\n    });\n$('#gohighlvel-multistep .glp-submit-btn').on('click', function (e) {\n\n    e.preventDefault();\n\n    \/\/ Current Button\n    let currentBtn = $(this);\n\n    \/\/ Current Active Step from button parent\n    let currentStepDiv = currentBtn.closest('.glp-step');\n\n    let step = currentStepDiv.data('step');\n\n    \/\/ Validate Current Step\n    if (!validateStep(step, currentStepDiv)) {\n        return;\n    }\n\n    \/\/ Current Form from button parent\n    let form = currentBtn.closest('form')[0];\n\n    let formData = new FormData(form);\n\n    $.ajax({\n        url: glp_ajax.ajax_url,\n        type: 'POST',\n        data: formData,\n        processData: false,\n        contentType: false,\n\n        beforeSend: function () {\n\n            currentBtn\n                .prop('disabled', true)\n                .text('Submitting...');\n\n        },\n\n        success: function (response) {\n\n            if (response.success) {\n\n                   const form = $('#gohighlvel-multistep');\n\n    const firstName = form.find('input[name=\"first_name\"]').val();\n    const lastName  = form.find('input[name=\"last_name\"]').val();\n    const email     = form.find('input[name=\"email\"]').val();\n    const phone     = form.find('input[name=\"contact_phone\"]').val();\n\n    form.html(`\n        <div class=\"glp-success-message\">\n\n            <div class=\"glp-success-icon\">\u2713<\/div>\n\n            <h2>Thank You, ${firstName} ${lastName}!<\/h2>\n\n            <p>\n                We have received your request successfully.\n            <\/p>\n\n            <p>\n                Our medical team will review your information and connect with you within 1\u20132 business days.\n            <\/p>\n\n            <div class=\"glp-success-user-info\">\n                <p><strong>Email:<\/strong> ${email}<\/p>\n                <p><strong>Phone:<\/strong> ${phone}<\/p>\n            <\/div>\n\n        <\/div>\n    `);\n\n\n            } else {\n\n               \/\/ alert(response.data.message);\n\n            }\n\n        },\n\n        complete: function () {\n\n            currentBtn\n                .prop('disabled', false)\n                .text('Submit');\n\n        }\n\n    });\n\n});\n});\n\/\/ Remove error class only if checked\njQuery(document).ready(function ($) {\n\n    $('#gohighlvel-multistep').on('change', 'input[type=\"radio\"], input[type=\"checkbox\"]', function () {\n\n        if ($(this).is(':checked')) {\n\n            \/\/ Remove error from current option\n            $(this).closest('.glp-option').removeClass('error-field');\n\n            \/\/ Remove error from entire group\n            $(this).closest('.glp-radio-group, .glp-checkbox-group')\n                   .find('.glp-option')\n                   .removeClass('error-field');\n        }\n\n    });\n\n});\n    <\/script>\n    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