GlamDerm - Gramercy Laser and Medical Dermatology

.payment-subform {
padding: 10px;
border: 2px double;
}
.payment-form {
display: table;
margin: 3px;
}
.payment-subform input, .payment-subform label {
display: table-cell;
}
.payment-subform-line {
display: table-row;
}
label.payment-subform-inline, input.payment-subform-inline {
display: inline;
}
#pjHiddenErrorMessage {
color: red;
visibility: hidden;
}
h2 { margin-bottom: 0 !important; }
form#pjQuickShopCustomForm > input, form#pjQuickShopCustomForm > br { display: none !important; margin: 0 !important; }
h3 { display: block !important; }
.form-row { display: block !important; }
.form-row-col { display: block !important; float: left !important; }
.form-row-clear { height: 0; line-height: 0; border: 0; clear: both; }

function pjPatientIsCardholder() {
var chxbox = document.querySelector(‘#pj-patient-is-card-holder’);
if (chxbox.checked) {
document.querySelector(‘#pj-cardholder-first-name’).value = document.querySelector(‘#pj-patient-first-name’).value;
document.querySelector(‘#pj-cardholder-last-name’).value = document.querySelector(‘#pj-patient-last-name’).value;
document.querySelector(‘#pj-cardholder-street-address’).value = document.querySelector(‘#pj-patient-street-address’).value;
document.querySelector(‘#pj-cardholder-city’).value = document.querySelector(‘#pj-patient-city’).value;
document.querySelector(‘#pj-cardholder-state’).value = document.querySelector(‘#pj-patient-state’).value;
document.querySelector(‘#pj-cardholder-zip’).value = document.querySelector(‘#pj-patient-zip’).value;
document.querySelector(‘#pj-cardholder-phone’).value = document.querySelector(‘#pj-patient-phone’).value;
document.querySelector(‘#pj-cardholder-email’).value = document.querySelector(‘#pj-patient-email’).value;
} else {
document.querySelector(‘#pj-cardholder-first-name’).value = ”;
document.querySelector(‘#pj-cardholder-last-name’).value = ”;
document.querySelector(‘#pj-cardholder-street-address’).value = ”;
document.querySelector(‘#pj-cardholder-city’).value = ”;
document.querySelector(‘#pj-cardholder-state’).value = ”;
document.querySelector(‘#pj-cardholder-zip’).value = ”;
document.querySelector(‘#pj-cardholder-phone’).value = ”;
document.querySelector(‘#pj-cardholder-email’).value = ”;
}
}
function validatePJForm(form) {

var toValidate = [
‘#pj-patient-first-name’,
‘#pj-patient-last-name’,
‘#pj-patient-account-number’,
‘#pj-cardholder-first-name’,
‘#pj-cardholder-last-name’,
‘#pj-cardholder-street-address’,
‘#pj-cardholder-city’,
‘#pj-cardholder-state’,
‘#pj-cardholder-zip’,
‘#pj-cardholder-email’
];

var failed = 0;
for (var index in toValidate) {
if (!document.querySelector(toValidate[index]).value) {
failed++;
document.querySelector(toValidate[index]).previousElementSibling.style.color = ‘red’;
} else {
document.querySelector(toValidate[index]).previousElementSibling.style.color = ”;
}
}

var paymentReason = document.querySelector(‘#pjQuickShopCustomForm input[type=”checkbox”]:not(#pj-patient-is-card-holder):checked’);

if (!paymentReason) {
failed++;
var reasons = document.querySelectorAll(‘#pj-payment-account-balance,#pj-payment-other,#pj-payment-prepayment’);
for (var el in reasons) {
var label = reasons[el].nextElementSibling;
if (label) label.style.color = ‘red’;
}
}

var amount = form.price.value;

if (amount == ” || isNaN(amount)) failed++;

if (failed > 0) {
document.querySelector(‘#pjHiddenErrorMessage’).style.visibility = ‘visible’;
return false;
}

switch(paymentReason.id) {
case ‘pj-payment-account-balance’:
form.notes.value += ‘Payment on Account Balancen’;
break;
case ‘pj-payment-prepayment’:
form.notes.value += ‘Pre Paymentn’;
break;
case ‘pj-payment-other’:
form.notes.value += ‘Other: ‘ + document.querySelector(‘#pj-payment-other-text’).value.trim() + ‘n’;
break;
}

form.notes.value += ‘Patient DOB: ‘ + document.querySelector(‘#pj-patient-dob’).value.trim() + ‘n’;

if (!document.querySelector(‘#pj-patient-is-card-holder’).checked) {
form.notes.value += ‘Patient Name: ‘ + document.querySelector(‘#pj-patient-first-name’).value.trim() + ‘ ‘ + document.querySelector(‘#pj-patient-last-name’).value.trim() + ‘n’;
form.notes.value += ‘Patient Billing Address: ‘ + document.querySelector(‘#pj-patient-street-address’).value.trim() + ‘n’;
form.notes.value += ‘City: ‘ + document.querySelector(‘#pj-patient-city’).value.trim() + ‘n’;
form.notes.value += ‘State: ‘ + document.querySelector(‘#pj-patient-state’).value.trim() + ‘n’;
form.notes.value += ‘Zip: ‘ + document.querySelector(‘#pj-patient-zip’).value.trim() + ‘n’;
form.notes.value += ‘Patient Phone: ‘ + document.querySelector(‘#pj-patient-phone’).value.trim() + ‘n’;
form.notes.value += ‘Patient Email: ‘ + document.querySelector(‘#pj-patient-email’).value.trim() + ‘n’;
} else {
form.notes.value += ‘Patient is the card holder’;
}

return true;
}
function pjPaymentReason(input) {
if (input.checked) {
var boxes = document.querySelectorAll(‘#pjQuickShopCustomForm input’);
for (var x in boxes) {
if (boxes[x].id == ‘pj-patient-is-card-holder’) continue;
if (boxes[x].type == ‘checkbox’ && boxes[x] !== input) boxes[x].checked = false;
}
}
}

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PATIENT INFORMATION

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CARD HOLDER INFORMATION

Select
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming


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