{"id":5415,"date":"2026-06-07T16:34:37","date_gmt":"2026-06-07T16:34:37","guid":{"rendered":"https:\/\/myvidamed.com\/?page_id=5415"},"modified":"2026-06-25T16:40:47","modified_gmt":"2026-06-25T16:40:47","slug":"lp-intake-form-v3","status":"publish","type":"page","link":"https:\/\/myvidamed.com\/en\/lp-intake-form-v3\/","title":{"rendered":"Vidamed Call Center Intake Form"},"content":{"rendered":"\n<div class=\"wp-block-group is-layout-constrained wp-block-group-is-layout-constrained\"><h2 class=\"wp-block-post-title\">Vidamed Call Center Intake Form<\/h2><\/div>\n\n\n<div id=\"glp-form\" class=\"glp-cc-form \">\r\n   \r\n<form id=\"cc-step-form\" method=\"post\" enctype=\"multipart\/form-data\" novalidate>\r\n<input type=\"hidden\" name=\"action\" value=\"save_call_center_form\" \/> \r\n\r\n\r\n<!-- STEP 1 \u2014 Contact Information -->\r\n<div class=\"glp-step active\" data-step=\"1\">\r\n\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>First Name*<\/label>\r\n    <input name=\"name\" required autocomplete=\"off\" type=\"text\">\r\n  <\/div>\r\n   <div class=\"col-6 mb-3 relative\">\r\n    <label>Last Name*<\/label>\r\n    <input type=\"text\" name=\"last_name\" required autocomplete=\"off\">\r\n  <\/div>\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>Phone*<\/label>\r\n    <input name=\"phone\" required autocomplete=\"off\" class=\"us-phone\"\r\n       value=\"+1 (___) ___ - ____\" mask=\"+1 (___) ___ - ____\" placeholder=\"+1 (___) ___ - ____\" >\r\n  <\/div>\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <label>Email*<\/label>\r\n    <input type=\"email\" name=\"email\" required autocomplete=\"email\">\r\n  <\/div>\r\n\r\n  <div class=\"col-6 mb-3 relative\">\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"2\">\r\n\r\n\r\n\r\n  <div class=\"glp-question-block\">\r\n\r\n    <p class=\"glp-question mb-5\">\r\n      Do you know your BMI (Body Mass Index)?      <span class=\"required\">*<\/span>\r\n    <\/p>\r\n\r\n    <div class=\"glp-row\">\r\n\r\n      <!-- Height FT -->\r\n      <div class=\"glp-field\">\r\n        <label>Height (ft)<\/label>\r\n        <input type=\"number\" name=\"height_ft\" min=\"1\" max=\"8\" required>\r\n        <small class=\"glp-help-text\">Please enter a number greater than or equal to 1<\/small>\r\n        <small class=\"glp-error-text\" data-error=\"height_ft\"><\/small>\r\n      <\/div>\r\n\r\n      <!-- Height IN -->\r\n      <div class=\"glp-field\">\r\n        <label>Height (in)<\/label>\r\n        <input type=\"number\" name=\"height_in\" min=\"0\" max=\"11\" required>\r\n        <small class=\"glp-help-text\">Please enter a number from 0 to 11<\/small>\r\n        <small class=\"glp-error-text\" data-error=\"height_in\"><\/small>\r\n      <\/div>\r\n\r\n    <\/div>\r\n\r\n    <!-- Weight -->\r\n    <div class=\"glp-field\">\r\n      <label>Weight (lbs)<\/label>\r\n      <input type=\"number\" name=\"weight\" id=\"weight\" min=\"50\" max=\"700\" required>\r\n      <small class=\"glp-error-text\" data-error=\"weight\"><\/small>\r\n    <\/div>\r\n\r\n    <!-- BMI -->\r\n    <div class=\"glp-field\">\r\n      <label>BMI<\/label>\r\n      <input type=\"text\" name=\"bmi\" id=\"bmi\" readonly>\r\n    <\/div>\r\n\r\n  <\/div>\r\n\r\n  <div class=\"glp-navigation\">\r\n    <button type=\"button\" class=\"prev\">Back<\/button>\r\n    <button type=\"button\" class=\"next\">Continue<\/button>\r\n  <\/div>\r\n\r\n<\/div>\r\n\r\n<div class=\"glp-step\" data-step=\"2\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_2\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        How old are you? (Just a number, but it helps us tailor our recommendations!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_2\"\n                    type=\"text\"\n                    name=\"question_2\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"3\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_3\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently taking any GLP-1 medications? (Medications like Ozempic, Wegovy, etc.)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_3\"\n                value=\"Yes\"\n                required            >\n                                    Yes        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_3\"\n                value=\"No\"\n                            >\n                                    No        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"4\">\r\n\r\n    \n    <div class=\"glp-question-block  has-condition wrap_question_4\"\n                         data-question-index=\"3\"\n            data-condition-response=\"Yes\"\n         >\n\n        <p class=\"glp-question mb-5\">\n        If yes, which one are you taking? (Please select the name!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_4[]\"\n                            value=\"Compounded Semaglutide Injections\"\n                        >\n                        Compounded Semaglutide Injections                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_4[]\"\n                            value=\"Compounded Tirzepatide Injections\"\n                        >\n                        Compounded Tirzepatide Injections                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_4[]\"\n                            value=\"Branded Semaglutide (Wegovy or Ozempic)\"\n                        >\n                        Branded Semaglutide (Wegovy or Ozempic)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_4[]\"\n                            value=\"Branded Tirzepatide (Zepbound or Mounjaro)\"\n                        >\n                        Branded Tirzepatide (Zepbound or Mounjaro)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_4[]\"\n                            value=\"Oral Semaglutide\"\n                        >\n                        Oral Semaglutide                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_4[]\"\n                            value=\"Oral Tirzepatide\"\n                        >\n                        Oral Tirzepatide                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"5\">\r\n\r\n    \n    <div class=\"glp-question-block  has-condition wrap_question_5\"\n                         data-question-index=\"3\"\n            data-condition-response=\"Yes\"\n         >\n\n        <p class=\"glp-question mb-5\">\n        When was your last dose? (An estimate is fine!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                     id =\"question_5\"\n                    type=\"date\"\n                    name=\"question_5\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"6\">\r\n\r\n    \n    <div class=\"glp-question-block  has-condition wrap_question_6\"\n                         data-question-index=\"3\"\n            data-condition-response=\"Yes\"\n         >\n\n        <p class=\"glp-question mb-5\">\n        What was the strength of your last dose? (In milligrams (mg) if you know it!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_6\"\n                    type=\"text\"\n                    name=\"question_6\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"7\">\r\n\r\n    \n    <div class=\"glp-question-block  has-condition wrap_question_7\"\n                         data-question-index=\"3\"\n            data-condition-response=\"Yes\"\n         >\n\n        <p class=\"glp-question mb-5\">\n        How are you doing with your medication? (Are you noticing any side effects? Is it working well for you? We&#039;d love to hear your thoughts!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"I\u2019m NOT losing weight (1-2 pounds\/week) and I\u2019m NOT having side effects.\"\n                required            >\n                                    I\u2019m NOT losing weight (1-2 pounds\/week) and I\u2019m NOT having side effects.        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"I\u2019m NOT losing weight (1-2 pounds\/week) and I AM having side effects.\"\n                            >\n                                    I\u2019m NOT losing weight (1-2 pounds\/week) and I AM having side effects.        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"I\u2019m losing weight (1-2 pounds\/week) but I AM having side effects.\"\n                            >\n                                    I\u2019m losing weight (1-2 pounds\/week) but I AM having side effects.        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_7\"\n                value=\"I\u2019m losing weight (1-2 pounds\/week) and I\u2019m NOT having side effects.\"\n                            >\n                                    I\u2019m losing weight (1-2 pounds\/week) and I\u2019m NOT having side effects.        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"8\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_8\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Is there a particular medication you are interested in discussing with your provider? (Please list below)                    <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_8\"\n                value=\"Compounded Semaglutide Injections\"\n                            >\n                                    Compounded Semaglutide Injections        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_8\"\n                value=\"Oral Semaglutide Tablets\"\n                            >\n                                    Oral Semaglutide Tablets        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_8\"\n                value=\"No preference, go with doctor recommendation\"\n                            >\n                                    No preference, go with doctor recommendation        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"9\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_9\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you pregnant, breastfeeding, or planning to be in the next 2 months? (This helps us provide the safest recommendations!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                <label class=\"glp-option\">\n                    <input type=\"radio\" name=\"question_9\" value=\"Yes\">\n                    Yes                <\/label>\n\n                <label class=\"glp-option\">\n                    <input type=\"radio\" name=\"question_9\" value=\"No\">\n                    No                <\/label>\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"10\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_10\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Do you have any of the following conditions? Did you have any in the past? (Select any that apply.)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-options\">\n                \n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Gastroparesis\"\n                        >\n                        Gastroparesis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Pancreatitis\"\n                        >\n                        Pancreatitis                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Type 1 diabetes or diabetes requiring insulin\"\n                        >\n                        Type 1 diabetes or diabetes requiring insulin                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Hypoglycemia\"\n                        >\n                        Hypoglycemia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Medullary Thyroid Cancer (MTC) or family history of MTC\"\n                        >\n                        Medullary Thyroid Cancer (MTC) or family history of MTC                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Bipolar Disorder\"\n                        >\n                        Bipolar Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Schizophrenia\"\n                        >\n                        Schizophrenia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome\"\n                        >\n                        Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Anorexia or Bulimia\"\n                        >\n                        Anorexia or Bulimia                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Current symptomatic gallstones or active gallbladder disease\"\n                        >\n                        Current symptomatic gallstones or active gallbladder disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Active Substance Abuse Disorder\"\n                        >\n                        Active Substance Abuse Disorder                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Hypertension (high blood pressure)\"\n                        >\n                        Hypertension (high blood pressure)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"High cholesterol\"\n                        >\n                        High cholesterol                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Type 2 diabetes\"\n                        >\n                        Type 2 diabetes                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Obstructive sleep apnea\"\n                        >\n                        Obstructive sleep apnea                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Gout\"\n                        >\n                        Gout                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Metabolic syndrome\"\n                        >\n                        Metabolic syndrome                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Heart disease, stroke, or peripheral vascular disease\"\n                        >\n                        Heart disease, stroke, or peripheral vascular disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Heart Failure\"\n                        >\n                        Heart Failure                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Atrial fibrillation or flutter\"\n                        >\n                        Atrial fibrillation or flutter                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Tachycardia or fast heart rate\"\n                        >\n                        Tachycardia or fast heart rate                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Any ECG abnormality or heart rhythm abnormality\"\n                        >\n                        Any ECG abnormality or heart rhythm abnormality                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Gallbladder removed\"\n                        >\n                        Gallbladder removed                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Fatty Liver (MASLD or MASH)\"\n                        >\n                        Fatty Liver (MASLD or MASH)                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Cirrhosis or end-stage liver disease\"\n                        >\n                        Cirrhosis or end-stage liver disease                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Chronic Kidney Disease Stage 3 or greater\"\n                        >\n                        Chronic Kidney Disease Stage 3 or greater                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"Hypothyroidism, Hyperthyroidism, or Thyroid Issues\"\n                        >\n                        Hypothyroidism, Hyperthyroidism, or Thyroid Issues                    <\/label>\n                                    <label class=\"glp-option\">\n                        <input \n                            type=\"checkbox\"\n                            name=\"question_10[]\"\n                            value=\"None of these\"\n                        >\n                        None of these                    <\/label>\n                            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"11\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_11\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Are you currently taking any medications, including prescriptions, over-the-counter meds, or supplements? If yes, please list them here! (The more details, the better!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_11\"\n                    type=\"text\"\n                    name=\"question_11\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"12\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_12\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Have you ever had surgery? (If so, please list them or type \u201cN\/A\u201d if none.)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_12\"\n                    type=\"text\"\n                    name=\"question_12\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"13\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_13\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Do you have any allergies? (If none, just type \u201cN\/A.\u201d)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            <div class=\"glp-field\">\n                <input \n                    id =\"question_13\"\n                    type=\"text\"\n                    name=\"question_13\"\n                    class=\"glp-input\"\n                    required                >\n            <\/div>\n\n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"14\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_14\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Which type of consultation do you prefer? (Let us know what works best for you!)            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_14\"\n                value=\"Email and Text Message (Fastest Option)\"\n                required            >\n                                    Email and Text Message (Fastest Option)        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_14\"\n                value=\"Video\"\n                            >\n                                    Video        <\/label>\n            <label class=\"glp-option multi-option\">\n            <input \n                type=\"radio\"\n                name=\"question_14\"\n                value=\"Phone Call\"\n                            >\n                                    Phone Call        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"next\">\r\n                Continue            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n<div class=\"glp-step\" data-step=\"15\">\r\n\r\n    \n    <div class=\"glp-question-block  wrap_question_15\"\n             >\n\n        <p class=\"glp-question mb-5\">\n        Final Step! \u2013 Please confirm that all the information you&#039;ve provided is true and complete. Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.            <span class=\"required\">*<\/span>        <\/p>\n\n        \n            \n                    <!-- Show Radio Buttons -->\n                   \n                    \n                    <!-- Show Radio Buttons -->\n                \n<div class=\"glp-options\">\n            <label class=\"glp-option single-option\">\n            <input \n                type=\"checkbox\"\n                name=\"question_15[]\"\n                value=\"I agree and consent\"\n                required            >\n                                    I agree and consent        <\/label>\n    <\/div>\n\n\n                \n        \n    <\/div>\n\n    \r\n    <div class=\"glp-navigation\">\r\n        <button type=\"button\" class=\"prev\">Back<\/button>\r\n                            <button type=\"button\" class=\"glp-submit-btn\">\r\n                Submit            <\/button>\r\n        \r\n    <\/div>\r\n\r\n<\/div>\r\n\r\n<\/form>\r\n<\/div>\r\n\r\n<style>\r\n    .single-option:before {\r\n    display: none;\r\n}\r\n\r\n.single-option input[type=\"checkbox\"] {\r\n        display: block !important;\r\n    position: relative !important;\r\n    opacity: 1 !important;\r\n    pointer-events: auto;\r\n    width: 20px !important;\r\n    margin-right: 15px !important;\r\n    \r\n}\r\n\r\n<\/style>\r\n\r\n\r\n<script>\r\n  document.addEventListener('DOMContentLoaded', function () {\r\n\r\n    const form = {\r\n        currentStep: 0,\r\n        steps: document.querySelectorAll('.glp-step'),\r\n\r\n        showStep(index) {\r\n            this.steps.forEach(step => step.classList.remove('active'));\r\n            this.steps[index].classList.add('active');\r\n\r\n            window.scrollTo({\r\n                top: document.getElementById('glp-form').offsetTop - 100,\r\n                behavior: 'smooth'\r\n            });\r\n        },\r\n\r\n        validateStep(index) {\r\n            const step = this.steps[index];\r\n            let valid = true;\r\n\r\n            \/\/ Required inputs\r\n            const requiredFields = step.querySelectorAll('[required]');\r\n\r\n            requiredFields.forEach(field => {\r\n\r\n                if (field.type === 'radio') {\r\n                    const group = step.querySelectorAll(\r\n                        `input[name=\"${field.name}\"]`\r\n                    );\r\n\r\n                    const checked = [...group].some(r => r.checked);\r\n\r\n                    if (!checked) {\r\n                        valid = false;\r\n                    }\r\n\r\n                } else if (field.type === 'checkbox') {\r\n\r\n                    const group = step.querySelectorAll(\r\n                        `input[name=\"${field.name}\"]`\r\n                    );\r\n\r\n                    const checked = [...group].some(c => c.checked);\r\n\r\n                    if (!checked) {\r\n                        valid = false;\r\n                    }\r\n\r\n                } else if (!field.value.trim()) {\r\n                    valid = false;\r\n                    field.classList.add('error');\r\n                } else {\r\n                    field.classList.remove('error');\r\n                }\r\n\r\n            });\r\n\r\n            return valid;\r\n        },\r\n        checkConditions() {\r\n\r\n            document.querySelectorAll('.has-condition').forEach(el => {\r\n\r\n                const parentStep = el.closest('.glp-step');\r\n                const questionIndex = el.dataset.questionIndex;\r\n                const expectedResponse = el.dataset.conditionResponse;\r\n\r\n                const selected = document.querySelector(\r\n                    `[name=\"question_${questionIndex}\"]:checked`\r\n                )?.value;\r\n\r\n                parentStep.dataset.hidden =\r\n                    selected === expectedResponse ? 'false' : 'true';\r\n            });\r\n\r\n        },\r\n        next() {\r\n\r\n    if (!this.validateStep(this.currentStep)) {\r\n        return;\r\n    }\r\n\r\n    this.checkConditions();\r\n\r\n    let nextStep = this.currentStep + 1;\r\n\r\n    while (\r\n        nextStep < this.steps.length &&\r\n        this.steps[nextStep].dataset.hidden === 'true'\r\n    ) {\r\n        nextStep++;\r\n    }\r\n\r\n    if (nextStep < this.steps.length) {\r\n        this.currentStep = nextStep;\r\n        this.showStep(this.currentStep);\r\n    }\r\n},\r\nprev() {\r\n\r\n    let prevStep = this.currentStep - 1;\r\n\r\n    while (\r\n        prevStep >= 0 &&\r\n        this.steps[prevStep].dataset.hidden === 'true'\r\n    ) {\r\n        prevStep--;\r\n    }\r\n\r\n    if (prevStep >= 0) {\r\n        this.currentStep = prevStep;\r\n        this.showStep(this.currentStep);\r\n    }\r\n}\r\n\r\n    };\r\n\r\n    document.querySelectorAll('#cc-step-form .next').forEach(btn => {\r\n        btn.addEventListener('click', () => form.next());\r\n    });\r\n\r\n    document.querySelectorAll('#cc-step-form .prev').forEach(btn => {\r\n        btn.addEventListener('click', () => form.prev());\r\n    });\r\n\r\n    form.showStep(0);\r\n\r\n});\r\njQuery(function($){\r\nfunction validateStep(step, currentStepDiv) {\r\n\r\n    let valid = true;\r\n\r\n    \/\/ Remove old error states\r\n    currentStepDiv.find('.error-field').removeClass('error-field');\r\n\r\n    currentStepDiv.find('[required]').each(function () {\r\n\r\n        let field = $(this);\r\n        let value = $.trim(field.val());\r\n        let type  = field.attr('type');\r\n        let name  = field.attr('name');\r\n\r\n        \/\/ Radio \/ Checkbox\r\n        if (type === 'radio' || type === 'checkbox') {\r\n\r\n            if (!currentStepDiv.find('[name=\"' + name + '\"]:checked').length) {\r\n\r\n                valid = false;\r\n\r\n                field.closest('.glp-option').addClass('error-field');\r\n            }\r\n\r\n        } else {\r\n\r\n            \/\/ Empty validation\r\n            if (value === '') {\r\n\r\n                valid = false;\r\n\r\n                field.addClass('error-field');\r\n\r\n                return; \/\/ stop further validation for this field\r\n            }\r\n\r\n            \/\/ Email validation\r\n            if (type === 'email') {\r\n\r\n                let emailPattern = \/^[^\\s@]+@[^\\s@]+\\.[^\\s@]+$\/;\r\n\r\n                if (!emailPattern.test(value)) {\r\n\r\n                    valid = false;\r\n\r\n                    field.addClass('error-field');\r\n                }\r\n            }\r\n\r\n            \/\/ Phone validation\r\n            if (\r\n                name === 'contact_phone' ||\r\n                name === 'phone'\r\n            ) {\r\n\r\n                let cleanPhone = value.replace(\/\\D\/g, '');\r\n\r\n                if (cleanPhone.length < 10) {\r\n\r\n                    valid = false;\r\n\r\n                    field.addClass('error-field');\r\n                }\r\n            }\r\n        }\r\n\r\n    });\r\n\r\n    return valid;\r\n}   \r\n$('#cc-step-form .glp-submit-btn').on('click', function (e) {\r\n\r\n    e.preventDefault();\r\n\r\n    \/\/ Current Button\r\n    let currentBtn = $(this);\r\n\r\n    \/\/ Current Active Step from button parent\r\n    let currentStepDiv = currentBtn.closest('.glp-step');\r\n\r\n    let step = currentStepDiv.data('step');\r\n\r\n    \/\/ Validate Current Step\r\n    if (!validateStep(step, currentStepDiv)) {\r\n        return;\r\n    }\r\n\r\n    \/\/ Current Form from button parent\r\n    let form = currentBtn.closest('form')[0];\r\n\r\n    let formData = new FormData(form);\r\n\r\n    $.ajax({\r\n        url: glp_ajax.ajax_url,\r\n        type: 'POST',\r\n        data: formData,\r\n        processData: false,\r\n        contentType: false,\r\n\r\n        beforeSend: function () {\r\n\r\n            currentBtn\r\n                .prop('disabled', true)\r\n                .text('Submitting...');\r\n\r\n        },\r\n\r\n        success: function (response) {\r\n\r\n            if (response.success) {\r\n\r\n                   const form = $('#cc-step-form');\r\n\r\n    const firstName = form.find('input[name=\"name\"]').val();\r\n    const lastName  = form.find('input[name=\"last_name\"]').val();\r\n    const email     = form.find('input[name=\"email\"]').val();\r\n    const phone     = form.find('input[name=\"phone\"]').val();\r\n\r\n    form.html(`\r\n        <div class=\"glp-success-message\">\r\n\r\n            <div class=\"glp-success-icon\">\u2713<\/div>\r\n\r\n            <h2>Thank You, ${firstName} ${lastName}!<\/h2>\r\n\r\n            <p>\r\n                We have received your request successfully.\r\n            <\/p>\r\n\r\n            <p>\r\n                Our medical team will review your information and connect with you within 1\u20132 business days.\r\n            <\/p>\r\n\r\n            <div class=\"glp-success-user-info\">\r\n                <p><strong>Email:<\/strong> ${email}<\/p>\r\n                <p><strong>Phone:<\/strong> ${phone}<\/p>\r\n            <\/div>\r\n\r\n        <\/div>\r\n    `);\r\n\r\n\r\n            } else {\r\n\r\n               \/\/ alert(response.data.message);\r\n\r\n            }\r\n\r\n        },\r\n\r\n        complete: function () {\r\n\r\n            currentBtn\r\n                .prop('disabled', false)\r\n                .text('Submit');\r\n\r\n        }\r\n\r\n    });\r\n\r\n});\r\n})\r\n  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