.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;
}
}
}