Spaces:
Running
Running
Update index.html
Browse files- index.html +227 -18
index.html
CHANGED
|
@@ -1,19 +1,228 @@
|
|
| 1 |
-
<!
|
| 2 |
-
<html>
|
| 3 |
-
|
| 4 |
-
|
| 5 |
-
|
| 6 |
-
|
| 7 |
-
|
| 8 |
-
|
| 9 |
-
|
| 10 |
-
|
| 11 |
-
|
| 12 |
-
|
| 13 |
-
|
| 14 |
-
|
| 15 |
-
|
| 16 |
-
|
| 17 |
-
|
| 18 |
-
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| 19 |
</html>
|
|
|
|
| 1 |
+
<!DOCTYPE html>
|
| 2 |
+
<html lang="en">
|
| 3 |
+
<head>
|
| 4 |
+
<meta charset="UTF-8" />
|
| 5 |
+
<meta name="viewport" content="width=device-width, initial-scale=1.0" />
|
| 6 |
+
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
|
| 7 |
+
<title>Your Page Title</title>
|
| 8 |
+
<link rel="stylesheet" href="style.css" />
|
| 9 |
+
<!-- You can add more meta tags, favicon, fonts, or libraries here -->
|
| 10 |
+
</head>
|
| 11 |
+
<body>
|
| 12 |
+
|
| 13 |
+
<div class="fl-row fl-row-full-width fl-row-bg-color fl-node-rnf7ijx1cum4 fl-row-default-height fl-row-align-center" data-node="rnf7ijx1cum4" bis_skin_checked="1">
|
| 14 |
+
<div class="fl-row-content-wrap" bis_skin_checked="1">
|
| 15 |
+
<div class="fl-row-content fl-row-fixed-width fl-node-content" bis_skin_checked="1">
|
| 16 |
+
|
| 17 |
+
<div class="fl-col-group fl-node-odyfnkg9vm06" data-node="odyfnkg9vm06" bis_skin_checked="1">
|
| 18 |
+
<div id="online-form" class="fl-col fl-node-90icod85lnb6 fl-col-bg-color" data-node="90icod85lnb6" bis_skin_checked="1">
|
| 19 |
+
<div class="fl-col-content fl-node-content" bis_skin_checked="1"><div class="fl-module fl-module-heading fl-node-8otvs9rnxaqb" data-node="8otvs9rnxaqb" bis_skin_checked="1">
|
| 20 |
+
<div class="fl-module-content fl-node-content" bis_skin_checked="1">
|
| 21 |
+
<h3 class="fl-heading">
|
| 22 |
+
<span class="fl-heading-text">Physician Referral</span>
|
| 23 |
+
</h3>
|
| 24 |
+
</div>
|
| 25 |
+
</div>
|
| 26 |
+
<div class="fl-module fl-module-widget fl-node-mpzlfwv9b5xg" data-node="mpzlfwv9b5xg" bis_skin_checked="1">
|
| 27 |
+
<div class="fl-module-content fl-node-content" bis_skin_checked="1">
|
| 28 |
+
<div class="fl-widget" bis_skin_checked="1">
|
| 29 |
+
<div class="widget gform_widget" bis_skin_checked="1"><script src="https://markhamfertility.com/wp-includes/js/dist/dom-ready.min.js?ver=f77871ff7694fffea381" id="wp-dom-ready-js"></script>
|
| 30 |
+
<script src="https://markhamfertility.com/wp-includes/js/dist/hooks.min.js?ver=4d63a3d491d11ffd8ac6" id="wp-hooks-js"></script>
|
| 31 |
+
<script src="https://markhamfertility.com/wp-includes/js/dist/i18n.min.js?ver=5e580eb46a90c2b997e6" id="wp-i18n-js"></script>
|
| 32 |
+
<script id="wp-i18n-js-after">
|
| 33 |
+
wp.i18n.setLocaleData( { 'text direction\u0004ltr': [ 'ltr' ] } );
|
| 34 |
+
</script>
|
| 35 |
+
<script src="https://markhamfertility.com/wp-includes/js/dist/a11y.min.js?ver=3156534cc54473497e14" id="wp-a11y-js"></script>
|
| 36 |
+
<link rel="stylesheet" id="dashicons-css" href="https://markhamfertility.com/wp-includes/css/dashicons.min.css?ver=6.8.2" media="all">
|
| 37 |
+
<script defer="defer" src="https://markhamfertility.com/wp-content/plugins/gravityforms/js/jquery.json.min.js?ver=2.9.13" id="gform_json-js"></script>
|
| 38 |
+
<script id="gform_gravityforms-js-extra">
|
| 39 |
+
var gform_i18n = {"datepicker":{"days":{"monday":"Mo","tuesday":"Tu","wednesday":"We","thursday":"Th","friday":"Fr","saturday":"Sa","sunday":"Su"},"months":{"january":"January","february":"February","march":"March","april":"April","may":"May","june":"June","july":"July","august":"August","september":"September","october":"October","november":"November","december":"December"},"firstDay":1,"iconText":"Select date"}};
|
| 40 |
+
var gf_legacy_multi = [];
|
| 41 |
+
var gform_gravityforms = {"strings":{"invalid_file_extension":"This type of file is not allowed. Must be one of the following:","delete_file":"Delete this file","in_progress":"in progress","file_exceeds_limit":"File exceeds size limit","illegal_extension":"This type of file is not allowed.","max_reached":"Maximum number of files reached","unknown_error":"There was a problem while saving the file on the server","currently_uploading":"Please wait for the uploading to complete","cancel":"Cancel","cancel_upload":"Cancel this upload","cancelled":"Cancelled"},"vars":{"images_url":"https:\/\/markhamfertility.com\/wp-content\/plugins\/gravityforms\/images"}};
|
| 42 |
+
var gf_legacy = {"is_legacy":""};
|
| 43 |
+
var gf_global = {"gf_currency_config":{"name":"U.S. Dollar","symbol_left":"$","symbol_right":"","symbol_padding":"","thousand_separator":",","decimal_separator":".","decimals":2,"code":"USD"},"base_url":"https:\/\/markhamfertility.com\/wp-content\/plugins\/gravityforms","number_formats":[],"spinnerUrl":"https:\/\/markhamfertility.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg","version_hash":"a8230eeef76dc62f09edb1cb9c41ec69","strings":{"newRowAdded":"New row added.","rowRemoved":"Row removed","formSaved":"The form has been saved. The content contains the link to return and complete the form."}};
|
| 44 |
+
</script>
|
| 45 |
+
<script defer="defer" src="https://markhamfertility.com/wp-content/plugins/gravityforms/js/gravityforms.min.js?ver=2.9.13" id="gform_gravityforms-js"></script>
|
| 46 |
+
<script src="https://markhamfertility.com/wp-includes/js/jquery/ui/core.min.js?ver=1.13.3" id="jquery-ui-core-js"></script>
|
| 47 |
+
<script src="https://markhamfertility.com/wp-includes/js/jquery/ui/datepicker.min.js?ver=1.13.3" id="jquery-ui-datepicker-js"></script>
|
| 48 |
+
<script defer="defer" src="https://markhamfertility.com/wp-content/plugins/gravityforms/js/datepicker-legacy.min.js?ver=2.9.13" id="gform_datepicker_legacy-js"></script>
|
| 49 |
+
<script defer="defer" src="https://markhamfertility.com/wp-content/plugins/gravityforms/js/datepicker.min.js?ver=2.9.13" id="gform_datepicker_init-js"></script>
|
| 50 |
+
<script src="https://markhamfertility.com/wp-includes/js/plupload/moxie.min.js?ver=1.3.5.1" id="moxiejs-js"></script>
|
| 51 |
+
<script src="https://markhamfertility.com/wp-includes/js/plupload/plupload.min.js?ver=2.1.9" id="plupload-js"></script>
|
| 52 |
+
<script defer="defer" src="https://markhamfertility.com/wp-content/plugins/gravityforms/js/jquery.maskedinput.min.js?ver=2.9.13" id="gform_masked_input-js"></script>
|
| 53 |
+
|
| 54 |
+
<div class="gf_browser_chrome gform_wrapper gravity-theme gform-theme--no-framework" data-form-theme="gravity-theme" data-form-index="0" id="gform_wrapper_2" bis_skin_checked="1">
|
| 55 |
+
<div class="gform_heading" bis_skin_checked="1">
|
| 56 |
+
<p class="gform_required_legend">"<span class="gfield_required gfield_required_asterisk">*</span>" indicates required fields</p>
|
| 57 |
+
</div><form method="post" enctype="multipart/form-data" id="gform_2" action="/physician-referral/" data-formid="2" novalidate="">
|
| 58 |
+
<div class="gform-body gform_body" bis_skin_checked="1"><div id="gform_fields_2" class="gform_fields top_label form_sublabel_above description_below validation_below" bis_skin_checked="1"><div id="field_2_15" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_hidden" bis_skin_checked="1"><div class="admin-hidden-markup" bis_skin_checked="1"><i class="gform-icon gform-icon--hidden" aria-hidden="true" title="This field is hidden when viewing the form"></i><span>This field is hidden when viewing the form</span></div><h3 class="gsection_title">Next Steps: Sync an Email Add-On</h3><div class="gsection_description" id="gfield_description_2_15" bis_skin_checked="1">To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.</div></div><div id="field_2_16" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_16">Date</label><div class="ginput_container ginput_container_date" bis_skin_checked="1">
|
| 59 |
+
<input name="input_16" id="input_2_16" type="text" value="23/07/2025" class="datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_2_16_date_format" aria-invalid="false">
|
| 60 |
+
<span id="input_2_16_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
|
| 61 |
+
</div>
|
| 62 |
+
<input type="hidden" id="gforms_calendar_icon_input_2_16" class="gform_hidden" value="https://markhamfertility.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg"></div><fieldset id="field_2_29" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label gfield_label_before_complex">Please check if</legend><div class="ginput_container ginput_container_checkbox" bis_skin_checked="1"><div class="gfield_checkbox " id="input_2_29" bis_skin_checked="1"><div class="gchoice gchoice_2_29_1" bis_skin_checked="1">
|
| 63 |
+
<input class="gfield-choice-input" name="input_29.1" type="checkbox" value="URGENT: Oncology or other medically necessary fertility preservation" id="choice_2_29_1">
|
| 64 |
+
<label for="choice_2_29_1" id="label_2_29_1" class="gform-field-label gform-field-label--type-inline">URGENT: Oncology or other medically necessary fertility preservation</label>
|
| 65 |
+
</div><div class="gchoice gchoice_2_29_2" bis_skin_checked="1">
|
| 66 |
+
<input class="gfield-choice-input" name="input_29.2" type="checkbox" value="MFC satellite partner" id="choice_2_29_2">
|
| 67 |
+
<label for="choice_2_29_2" id="label_2_29_2" class="gform-field-label gform-field-label--type-inline">MFC satellite partner</label>
|
| 68 |
+
</div><div class="gchoice gchoice_2_29_3" bis_skin_checked="1">
|
| 69 |
+
<input class="gfield-choice-input" name="input_29.3" type="checkbox" value="CSIO" id="choice_2_29_3">
|
| 70 |
+
<label for="choice_2_29_3" id="label_2_29_3" class="gform-field-label gform-field-label--type-inline">CSIO</label>
|
| 71 |
+
</div><div class="gchoice gchoice_2_29_4" bis_skin_checked="1">
|
| 72 |
+
<input class="gfield-choice-input" name="input_29.4" type="checkbox" value="Sprout" id="choice_2_29_4">
|
| 73 |
+
<label for="choice_2_29_4" id="label_2_29_4" class="gform-field-label gform-field-label--type-inline">Sprout</label>
|
| 74 |
+
</div></div></div></fieldset><fieldset id="field_2_42" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label">Refer to<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_container ginput_container_radio" bis_skin_checked="1"><div class="gfield_radio" id="input_2_42" bis_skin_checked="1">
|
| 75 |
+
<div class="gchoice gchoice_2_42_0" bis_skin_checked="1">
|
| 76 |
+
<input class="gfield-choice-input" name="input_42" type="radio" value="First available Specialist" id="choice_2_42_0" onchange="gformToggleRadioOther( this )">
|
| 77 |
+
<label for="choice_2_42_0" id="label_2_42_0" class="gform-field-label gform-field-label--type-inline">First available Specialist</label>
|
| 78 |
+
</div>
|
| 79 |
+
<div class="gchoice gchoice_2_42_1" bis_skin_checked="1">
|
| 80 |
+
<input class="gfield-choice-input" name="input_42" type="radio" value="Dr. Meivys Garcia" id="choice_2_42_1" onchange="gformToggleRadioOther( this )">
|
| 81 |
+
<label for="choice_2_42_1" id="label_2_42_1" class="gform-field-label gform-field-label--type-inline">Dr. Meivys Garcia</label>
|
| 82 |
+
</div>
|
| 83 |
+
<div class="gchoice gchoice_2_42_2" bis_skin_checked="1">
|
| 84 |
+
<input class="gfield-choice-input" name="input_42" type="radio" value="Dr. Marta Wais" id="choice_2_42_2" onchange="gformToggleRadioOther( this )">
|
| 85 |
+
<label for="choice_2_42_2" id="label_2_42_2" class="gform-field-label gform-field-label--type-inline">Dr. Marta Wais</label>
|
| 86 |
+
</div>
|
| 87 |
+
<div class="gchoice gchoice_2_42_3" bis_skin_checked="1">
|
| 88 |
+
<input class="gfield-choice-input" name="input_42" type="radio" value="Dr. Crystal Chan" id="choice_2_42_3" onchange="gformToggleRadioOther( this )">
|
| 89 |
+
<label for="choice_2_42_3" id="label_2_42_3" class="gform-field-label gform-field-label--type-inline">Dr. Crystal Chan</label>
|
| 90 |
+
</div>
|
| 91 |
+
<div class="gchoice gchoice_2_42_4" bis_skin_checked="1">
|
| 92 |
+
<input class="gfield-choice-input" name="input_42" type="radio" value="Dr. Salina Kanji" id="choice_2_42_4" onchange="gformToggleRadioOther( this )">
|
| 93 |
+
<label for="choice_2_42_4" id="label_2_42_4" class="gform-field-label gform-field-label--type-inline">Dr. Salina Kanji</label>
|
| 94 |
+
</div>
|
| 95 |
+
<div class="gchoice gchoice_2_42_5" bis_skin_checked="1">
|
| 96 |
+
<input class="gfield-choice-input" name="input_42" type="radio" value="Dr. Daphne Chong" id="choice_2_42_5" onchange="gformToggleRadioOther( this )">
|
| 97 |
+
<label for="choice_2_42_5" id="label_2_42_5" class="gform-field-label gform-field-label--type-inline">Dr. Daphne Chong</label>
|
| 98 |
+
</div></div></div></fieldset><div id="field_2_22" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><h3 class="gsection_title">Referring Physician Information</h3></div><fieldset id="field_2_23" class="gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_2_23" bis_skin_checked="1">
|
| 99 |
+
|
| 100 |
+
<span id="input_2_23_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
|
| 101 |
+
<label for="input_2_23_3" class="gform-field-label gform-field-label--type-sub ">First</label>
|
| 102 |
+
<input type="text" name="input_23.3" id="input_2_23_3" value="" aria-required="true" autocomplete="given-name">
|
| 103 |
+
</span>
|
| 104 |
+
|
| 105 |
+
<span id="input_2_23_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
|
| 106 |
+
<label for="input_2_23_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
|
| 107 |
+
<input type="text" name="input_23.6" id="input_2_23_6" value="" aria-required="true" autocomplete="family-name">
|
| 108 |
+
</span>
|
| 109 |
+
|
| 110 |
+
</div></fieldset><div id="field_2_18" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_18">OHIP Billing #<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_text" bis_skin_checked="1"><input name="input_18" id="input_2_18" type="text" value="" class="small" aria-required="true" aria-invalid="false"></div></div><div id="field_2_19" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_19">Physician Phone Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_phone" bis_skin_checked="1"><input name="input_19" id="input_2_19" type="tel" value="" class="large" aria-required="true" aria-invalid="false"><div data-lastpass-icon-root="" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;" bis_skin_checked="1"></div></div></div><div id="field_2_21" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_21">Fax Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_phone" bis_skin_checked="1"><input name="input_21" id="input_2_21" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div></div><div id="field_2_20" class="gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_20">Email Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_email" bis_skin_checked="1">
|
| 111 |
+
<input name="input_20" id="input_2_20" type="email" value="" class="large" aria-required="true" aria-invalid="false">
|
| 112 |
+
</div></div><fieldset id="field_2_43" class="gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label gfield_label_before_complex">Physician Address</legend>
|
| 113 |
+
<div class="ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row" id="input_2_43" bis_skin_checked="1">
|
| 114 |
+
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_2_43_1_container">
|
| 115 |
+
<label for="input_2_43_1" id="input_2_43_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
|
| 116 |
+
<input type="text" name="input_43.1" id="input_2_43_1" value="" aria-required="false">
|
| 117 |
+
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_2_43_3_container">
|
| 118 |
+
<label for="input_2_43_3" id="input_2_43_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
|
| 119 |
+
<input type="text" name="input_43.3" id="input_2_43_3" value="" aria-required="false">
|
| 120 |
+
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_2_43_4_container">
|
| 121 |
+
<label for="input_2_43_4" id="input_2_43_4_label" class="gform-field-label gform-field-label--type-sub ">Province</label>
|
| 122 |
+
<input type="text" name="input_43.4" id="input_2_43_4" value="" aria-required="false">
|
| 123 |
+
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_2_43_5_container">
|
| 124 |
+
<label for="input_2_43_5" id="input_2_43_5_label" class="gform-field-label gform-field-label--type-sub ">Postal Code</label>
|
| 125 |
+
<input type="text" name="input_43.5" id="input_2_43_5" value="" aria-required="false">
|
| 126 |
+
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_2_43_6_container">
|
| 127 |
+
<label for="input_2_43_6" id="input_2_43_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
|
| 128 |
+
<select name="input_43.6" id="input_2_43_6" aria-required="false"><option value=""></option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antarctica">Antarctica</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="Bahamas">Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Bouvet Island">Bouvet Island</option><option value="Brazil">Brazil</option><option value="British Indian Ocean Territory">British Indian Ocean Territory</option><option value="Brunei Darussalam">Brunei Darussalam</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cabo Verde">Cabo Verde</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada" selected="selected">Canada</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="China">China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos Islands">Cocos Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Curaçao">Curaçao</option><option value="Cyprus">Cyprus</option><option value="Czechia">Czechia</option><option value="Côte d'Ivoire">Côte d'Ivoire</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Guiana">French Guiana</option><option value="French Polynesia">French Polynesia</option><option value="French Southern Territories">French Southern Territories</option><option value="Gabon">Gabon</option><option value="Gambia">Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option><option value="Holy See">Holy See</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Isle of Man">Isle of Man</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option><option value="Korea, Republic of">Korea, Republic of</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macao">Macao</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="North Macedonia">North Macedonia</option><option value="Northern Mariana Islands">Northern Mariana Islands</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Palestine, State of">Palestine, State of</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn">Pitcairn</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russian Federation">Russian Federation</option><option value="Rwanda">Rwanda</option><option value="Réunion">Réunion</option><option value="Saint Barthélemy">Saint Barthélemy</option><option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Sint Maarten">Sint Maarten</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="South Africa">South Africa</option><option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option><option value="South Sudan">South Sudan</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria Arab Republic">Syria Arab Republic</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tunisia">Tunisia</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Türkiye">Türkiye</option><option value="US Minor Outlying Islands">US Minor Outlying Islands</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="United States">United States</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Venezuela">Venezuela</option><option value="Viet Nam">Viet Nam</option><option value="Virgin Islands, British">Virgin Islands, British</option><option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="Åland Islands">Åland Islands</option> </select>
|
| 129 |
+
</span>
|
| 130 |
+
<div class="gf_clear gf_clear_complex" bis_skin_checked="1"></div>
|
| 131 |
+
</div></fieldset><div id="field_2_7" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><h3 class="gsection_title">Patient Information</h3></div><fieldset id="field_2_1" class="gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_2_1" bis_skin_checked="1">
|
| 132 |
+
|
| 133 |
+
<span id="input_2_1_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
|
| 134 |
+
<label for="input_2_1_3" class="gform-field-label gform-field-label--type-sub ">First</label>
|
| 135 |
+
<input type="text" name="input_1.3" id="input_2_1_3" value="" aria-required="true" autocomplete="given-name">
|
| 136 |
+
</span>
|
| 137 |
+
|
| 138 |
+
<span id="input_2_1_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
|
| 139 |
+
<label for="input_2_1_6" class="gform-field-label gform-field-label--type-sub ">Last</label>
|
| 140 |
+
<input type="text" name="input_1.6" id="input_2_1_6" value="" aria-required="true" autocomplete="family-name">
|
| 141 |
+
</span>
|
| 142 |
+
|
| 143 |
+
</div></fieldset><div id="field_2_24" class="gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_24">Date of birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_date" bis_skin_checked="1">
|
| 144 |
+
<input name="input_24" id="input_2_24" type="text" value="" class="datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon hasDatepicker initialized" placeholder="dd/mm/yyyy" aria-describedby="input_2_24_date_format" aria-invalid="false" aria-required="true">
|
| 145 |
+
<span id="input_2_24_date_format" class="screen-reader-text">DD slash MM slash YYYY</span>
|
| 146 |
+
</div>
|
| 147 |
+
<input type="hidden" id="gforms_calendar_icon_input_2_24" class="gform_hidden" value="https://markhamfertility.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg"></div><fieldset id="field_2_25" class="gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-two-thirds gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label">Gender assigned at birth<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend><div class="ginput_container ginput_container_radio" bis_skin_checked="1"><div class="gfield_radio" id="input_2_25" bis_skin_checked="1">
|
| 148 |
+
<div class="gchoice gchoice_2_25_0" bis_skin_checked="1">
|
| 149 |
+
<input class="gfield-choice-input" name="input_25" type="radio" value="Male" id="choice_2_25_0" onchange="gformToggleRadioOther( this )">
|
| 150 |
+
<label for="choice_2_25_0" id="label_2_25_0" class="gform-field-label gform-field-label--type-inline">Male</label>
|
| 151 |
+
</div>
|
| 152 |
+
<div class="gchoice gchoice_2_25_1" bis_skin_checked="1">
|
| 153 |
+
<input class="gfield-choice-input" name="input_25" type="radio" value="Female" id="choice_2_25_1" onchange="gformToggleRadioOther( this )">
|
| 154 |
+
<label for="choice_2_25_1" id="label_2_25_1" class="gform-field-label gform-field-label--type-inline">Female</label>
|
| 155 |
+
</div></div></div></fieldset><div id="field_2_40" class="gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_40">OHIP (with Version Code)<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_text" bis_skin_checked="1"><input name="input_40" id="input_2_40" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div></div><fieldset id="field_2_39" class="gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label gfield_label_before_complex">Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></legend>
|
| 156 |
+
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row" id="input_2_39" bis_skin_checked="1">
|
| 157 |
+
<span class="ginput_full address_line_1 ginput_address_line_1 gform-grid-col" id="input_2_39_1_container">
|
| 158 |
+
<label for="input_2_39_1" id="input_2_39_1_label" class="gform-field-label gform-field-label--type-sub ">Street Address</label>
|
| 159 |
+
<input type="text" name="input_39.1" id="input_2_39_1" value="" aria-required="true">
|
| 160 |
+
<div data-lastpass-icon-root="" style="position: relative !important; height: 0px !important; width: 0px !important; float: left !important;" bis_skin_checked="1"></div></span><span class="ginput_full address_line_2 ginput_address_line_2 gform-grid-col" id="input_2_39_2_container">
|
| 161 |
+
<label for="input_2_39_2" id="input_2_39_2_label" class="gform-field-label gform-field-label--type-sub ">Address Line 2</label>
|
| 162 |
+
<input type="text" name="input_39.2" id="input_2_39_2" value="" aria-required="false">
|
| 163 |
+
</span><span class="ginput_left address_city ginput_address_city gform-grid-col" id="input_2_39_3_container">
|
| 164 |
+
<label for="input_2_39_3" id="input_2_39_3_label" class="gform-field-label gform-field-label--type-sub ">City</label>
|
| 165 |
+
<input type="text" name="input_39.3" id="input_2_39_3" value="" aria-required="true">
|
| 166 |
+
</span><span class="ginput_right address_state ginput_address_state gform-grid-col" id="input_2_39_4_container">
|
| 167 |
+
<label for="input_2_39_4" id="input_2_39_4_label" class="gform-field-label gform-field-label--type-sub ">State / Province / Region</label>
|
| 168 |
+
<input type="text" name="input_39.4" id="input_2_39_4" value="" aria-required="true">
|
| 169 |
+
</span><span class="ginput_left address_zip ginput_address_zip gform-grid-col" id="input_2_39_5_container">
|
| 170 |
+
<label for="input_2_39_5" id="input_2_39_5_label" class="gform-field-label gform-field-label--type-sub ">ZIP / Postal Code</label>
|
| 171 |
+
<input type="text" name="input_39.5" id="input_2_39_5" value="" aria-required="true">
|
| 172 |
+
</span><span class="ginput_right address_country ginput_address_country gform-grid-col" id="input_2_39_6_container">
|
| 173 |
+
<label for="input_2_39_6" id="input_2_39_6_label" class="gform-field-label gform-field-label--type-sub ">Country</label>
|
| 174 |
+
<select name="input_39.6" id="input_2_39_6" aria-required="true"><option value="" selected="selected"></option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antarctica">Antarctica</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="Bahamas">Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bonaire, Sint Eustatius and Saba">Bonaire, Sint Eustatius and Saba</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Bouvet Island">Bouvet Island</option><option value="Brazil">Brazil</option><option value="British Indian Ocean Territory">British Indian Ocean Territory</option><option value="Brunei Darussalam">Brunei Darussalam</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cabo Verde">Cabo Verde</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="China">China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos Islands">Cocos Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Congo, Democratic Republic of the">Congo, Democratic Republic of the</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Curaçao">Curaçao</option><option value="Cyprus">Cyprus</option><option value="Czechia">Czechia</option><option value="Côte d'Ivoire">Côte d'Ivoire</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Guiana">French Guiana</option><option value="French Polynesia">French Polynesia</option><option value="French Southern Territories">French Southern Territories</option><option value="Gabon">Gabon</option><option value="Gambia">Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Heard Island and McDonald Islands">Heard Island and McDonald Islands</option><option value="Holy See">Holy See</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Isle of Man">Isle of Man</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option><option value="Korea, Republic of">Korea, Republic of</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macao">Macao</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option value="Montserrat">Montserrat</option><option value="Morocco">Morocco</option><option value="Mozambique">Mozambique</option><option value="Myanmar">Myanmar</option><option value="Namibia">Namibia</option><option value="Nauru">Nauru</option><option value="Nepal">Nepal</option><option value="Netherlands">Netherlands</option><option value="New Caledonia">New Caledonia</option><option value="New Zealand">New Zealand</option><option value="Nicaragua">Nicaragua</option><option value="Niger">Niger</option><option value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="North Macedonia">North Macedonia</option><option value="Northern Mariana Islands">Northern Mariana Islands</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Palestine, State of">Palestine, State of</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn">Pitcairn</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russian Federation">Russian Federation</option><option value="Rwanda">Rwanda</option><option value="Réunion">Réunion</option><option value="Saint Barthélemy">Saint Barthélemy</option><option value="Saint Helena, Ascension and Tristan da Cunha">Saint Helena, Ascension and Tristan da Cunha</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Sint Maarten">Sint Maarten</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="South Africa">South Africa</option><option value="South Georgia and the South Sandwich Islands">South Georgia and the South Sandwich Islands</option><option value="South Sudan">South Sudan</option><option value="Spain">Spain</option><option value="Sri Lanka">Sri Lanka</option><option value="Sudan">Sudan</option><option value="Suriname">Suriname</option><option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option><option value="Sweden">Sweden</option><option value="Switzerland">Switzerland</option><option value="Syria Arab Republic">Syria Arab Republic</option><option value="Taiwan">Taiwan</option><option value="Tajikistan">Tajikistan</option><option value="Tanzania, the United Republic of">Tanzania, the United Republic of</option><option value="Thailand">Thailand</option><option value="Timor-Leste">Timor-Leste</option><option value="Togo">Togo</option><option value="Tokelau">Tokelau</option><option value="Tonga">Tonga</option><option value="Trinidad and Tobago">Trinidad and Tobago</option><option value="Tunisia">Tunisia</option><option value="Turkmenistan">Turkmenistan</option><option value="Turks and Caicos Islands">Turks and Caicos Islands</option><option value="Tuvalu">Tuvalu</option><option value="Türkiye">Türkiye</option><option value="US Minor Outlying Islands">US Minor Outlying Islands</option><option value="Uganda">Uganda</option><option value="Ukraine">Ukraine</option><option value="United Arab Emirates">United Arab Emirates</option><option value="United Kingdom">United Kingdom</option><option value="United States">United States</option><option value="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Venezuela">Venezuela</option><option value="Viet Nam">Viet Nam</option><option value="Virgin Islands, British">Virgin Islands, British</option><option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option><option value="Wallis and Futuna">Wallis and Futuna</option><option value="Western Sahara">Western Sahara</option><option value="Yemen">Yemen</option><option value="Zambia">Zambia</option><option value="Zimbabwe">Zimbabwe</option><option value="Åland Islands">Åland Islands</option> </select>
|
| 175 |
+
</span>
|
| 176 |
+
<div class="gf_clear gf_clear_complex" bis_skin_checked="1"></div>
|
| 177 |
+
</div></fieldset><div id="field_2_26" class="gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_26">Preferred email for communication<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_email" bis_skin_checked="1">
|
| 178 |
+
<input name="input_26" id="input_2_26" type="email" value="" class="large" aria-required="true" aria-invalid="false">
|
| 179 |
+
</div></div><div id="field_2_27" class="gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_27">Patient Phone Number<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_phone" bis_skin_checked="1"><input name="input_27" id="input_2_27" type="tel" value="" class="large" aria-required="true" aria-invalid="false"></div></div><div id="field_2_11" class="gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_11">Preferred Method of Contact</label><div class="ginput_container ginput_container_select" bis_skin_checked="1"><select name="input_11" id="input_2_11" class="large gfield_select" aria-invalid="false"><option value="Email">Email</option><option value="Phone">Phone</option></select></div></div><div id="field_2_33" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><h3 class="gsection_title">Referring Information for Oncology Patients</h3><div class="gsection_description" id="gfield_description_2_33" bis_skin_checked="1">Please attach all notes/reports. Oncology patients will be contacted within 24 hours.</div></div><div id="field_2_34" class="gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_34">Diagnosis</label><div class="ginput_container ginput_container_text" bis_skin_checked="1"><input name="input_34" id="input_2_34" type="text" value="" class="medium" aria-invalid="false"></div></div><fieldset id="field_2_35" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible"><legend class="gfield_label gform-field-label gfield_label_before_complex">Check all that apply</legend><div class="ginput_container ginput_container_checkbox" bis_skin_checked="1"><div class="gfield_checkbox " id="input_2_35" bis_skin_checked="1"><div class="gchoice gchoice_2_35_1" bis_skin_checked="1">
|
| 180 |
+
<input class="gfield-choice-input" name="input_35.1" type="checkbox" value="Chemotherapy" id="choice_2_35_1">
|
| 181 |
+
<label for="choice_2_35_1" id="label_2_35_1" class="gform-field-label gform-field-label--type-inline">Chemotherapy</label>
|
| 182 |
+
</div><div class="gchoice gchoice_2_35_2" bis_skin_checked="1">
|
| 183 |
+
<input class="gfield-choice-input" name="input_35.2" type="checkbox" value="Radiation Therapy" id="choice_2_35_2">
|
| 184 |
+
<label for="choice_2_35_2" id="label_2_35_2" class="gform-field-label gform-field-label--type-inline">Radiation Therapy</label>
|
| 185 |
+
</div><div class="gchoice gchoice_2_35_3" bis_skin_checked="1">
|
| 186 |
+
<input class="gfield-choice-input" name="input_35.3" type="checkbox" value="Surgery" id="choice_2_35_3">
|
| 187 |
+
<label for="choice_2_35_3" id="label_2_35_3" class="gform-field-label gform-field-label--type-inline">Surgery</label>
|
| 188 |
+
</div><div class="gchoice gchoice_2_35_4" bis_skin_checked="1">
|
| 189 |
+
<input class="gfield-choice-input" name="input_35.4" type="checkbox" value="Treatment completed" id="choice_2_35_4">
|
| 190 |
+
<label for="choice_2_35_4" id="label_2_35_4" class="gform-field-label gform-field-label--type-inline">Treatment completed</label>
|
| 191 |
+
</div></div></div></fieldset><div id="field_2_38" class="gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><h3 class="gsection_title"></h3></div><div id="field_2_28" class="gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="input_2_28">Please describe the reason(s) for referral<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class="ginput_container ginput_container_textarea" bis_skin_checked="1"><textarea name="input_28" id="input_2_28" class="textarea large" aria-required="true" aria-invalid="false" rows="10" cols="50"></textarea></div></div><div id="field_2_31" class="gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible" bis_skin_checked="1"><label class="gfield_label gform-field-label" for="html5_1j0r863u91c6e1rf9gch1haul8e3">Upload files</label><div class="ginput_container ginput_container_fileupload" bis_skin_checked="1"><div id="gform_multifile_upload_2_31" data-settings="{"runtimes":"html5,flash,html4","browse_button":"gform_browse_button_2_31","container":"gform_multifile_upload_2_31","drop_element":"gform_drag_drop_area_2_31","filelist":"gform_preview_2_31","unique_names":true,"file_data_name":"file","url":"https:\/\/markhamfertility.com\/?gf_page=6b8f8fcb0098abe","flash_swf_url":"https:\/\/markhamfertility.com\/wp-includes\/js\/plupload\/plupload.flash.swf","silverlight_xap_url":"https:\/\/markhamfertility.com\/wp-includes\/js\/plupload\/plupload.silverlight.xap","filters":{"mime_types":[{"title":"Allowed Files","extensions":"pdf,txt,doc,docx,html"}],"max_file_size":"268435456b"},"multipart":true,"urlstream_upload":false,"multipart_params":{"form_id":2,"field_id":31},"gf_vars":{"max_files":0,"message_id":"gform_multifile_messages_2_31","disallowed_extensions":["php","asp","aspx","cmd","csh","bat","html","htm","hta","jar","exe","com","js","lnk","htaccess","phtml","ps1","ps2","php3","php4","php5","php6","py","rb","tmp"]}}" class="gform_fileupload_multifile" style="position: relative;" bis_skin_checked="1">
|
| 192 |
+
<div id="gform_drag_drop_area_2_31" class="gform_drop_area gform-theme-field-control" style="position: relative;" bis_skin_checked="1">
|
| 193 |
+
<span class="gform_drop_instructions">Drop files here or </span>
|
| 194 |
+
<button type="button" id="gform_browse_button_2_31" class="button gform_button_select_files gform-theme-button gform-theme-button--control" aria-describedby="gfield_upload_rules_2_31 gfield_description_2_31" style="position: relative; z-index: 1;" aria-label="select files, upload files">Select files</button>
|
| 195 |
+
</div>
|
| 196 |
+
<div id="html5_1j0r863u91c6e1rf9gch1haul8e3_container" class="moxie-shim moxie-shim-html5" style="position: absolute; top: 64px; left: 270px; width: 111px; height: 33px; overflow: hidden; z-index: 0;" bis_skin_checked="1"><input id="html5_1j0r863u91c6e1rf9gch1haul8e3" type="file" style="font-size: 999px; opacity: 0; position: absolute; top: 0px; left: 0px; width: 100%; height: 100%;" multiple="" accept="application/pdf,.pdf,text/plain,.txt,application/msword,.doc,application/vnd.openxmlformats-officedocument.wordprocessingml.document,.docx,text/html,.html" tabindex="-1" aria-hidden="true"></div></div><span class="gfield_description gform_fileupload_rules" id="gfield_upload_rules_2_31">Accepted file types: pdf, txt, doc, docx, html, Max. file size: 256 MB.</span><ul class="validation_message--hidden-on-empty gform-ul-reset" id="gform_multifile_messages_2_31"></ul> <!-- Leave <ul> empty to support CSS :empty selector. --></div><div id="gform_preview_2_31" class="ginput_preview_list" bis_skin_checked="1"></div><div class="gfield_description" id="gfield_description_2_31" bis_skin_checked="1">Please include any relevant investigations and results for the patient and partner if applicable, previous fertility testing & treatments, bloodwork results from <1 year, ultrasounds, semen analysis, genetic testing, PAP results and abdominal or pelvic surgery reports. Thank you for trusting us with your patient’s care.
|
| 197 |
+
Markham Fertility Centre will contact your patient with the appointment date and time.</div></div></div></div>
|
| 198 |
+
<div class="gform-footer gform_footer top_label" bis_skin_checked="1"> <input type="submit" id="gform_submit_button_2" class="gform_button button" onclick="gform.submission.handleButtonClick(this);" data-submission-type="submit" value="Submit">
|
| 199 |
+
<input type="hidden" class="gform_hidden" name="gform_submission_method" data-js="gform_submission_method_2" value="postback">
|
| 200 |
+
<input type="hidden" class="gform_hidden" name="gform_theme" data-js="gform_theme_2" id="gform_theme_2" value="gravity-theme">
|
| 201 |
+
<input type="hidden" class="gform_hidden" name="gform_style_settings" data-js="gform_style_settings_2" id="gform_style_settings_2" value="">
|
| 202 |
+
<input type="hidden" class="gform_hidden" name="is_submit_2" value="1">
|
| 203 |
+
<input type="hidden" class="gform_hidden" name="gform_submit" value="2">
|
| 204 |
+
|
| 205 |
+
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
|
| 206 |
+
<input type="hidden" class="gform_hidden" name="state_2" value="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">
|
| 207 |
+
<input type="hidden" autocomplete="off" class="gform_hidden" name="gform_target_page_number_2" id="gform_target_page_number_2" value="0">
|
| 208 |
+
<input type="hidden" autocomplete="off" class="gform_hidden" name="gform_source_page_number_2" id="gform_source_page_number_2" value="1">
|
| 209 |
+
<input type="hidden" name="gform_field_values" value="">
|
| 210 |
+
<input type="hidden" name="gform_uploaded_files" id="gform_uploaded_files_2" value="">
|
| 211 |
+
</div>
|
| 212 |
+
</form>
|
| 213 |
+
</div><script>
|
| 214 |
+
gform.initializeOnLoaded( function() {gformInitSpinner( 2, 'https://markhamfertility.com/wp-content/plugins/gravityforms/images/spinner.svg', true );jQuery('#gform_ajax_frame_2').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_2');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_2').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_2').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_2').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_2').removeClass('gform_validation_error');}setTimeout( function() { /* delay the scroll by 50 milliseconds to fix a bug in chrome */ }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_2').val();gformInitSpinner( 2, 'https://markhamfertility.com/wp-content/plugins/gravityforms/images/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [2, current_page]);window['gf_submitting_2'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_2').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [2]);window['gf_submitting_2'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_2').text());}else{jQuery('#gform_2').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger("gform_pre_post_render", [{ formId: "2", currentPage: "current_page", abort: function() { this.preventDefault(); } }]); if (event && event.defaultPrevented) { return; } const gformWrapperDiv = document.getElementById( "gform_wrapper_2" ); if ( gformWrapperDiv ) { const visibilitySpan = document.createElement( "span" ); visibilitySpan.id = "gform_visibility_test_2"; gformWrapperDiv.insertAdjacentElement( "afterend", visibilitySpan ); } const visibilityTestDiv = document.getElementById( "gform_visibility_test_2" ); let postRenderFired = false; function triggerPostRender() { if ( postRenderFired ) { return; } postRenderFired = true; gform.core.triggerPostRenderEvents( 2, current_page ); if ( visibilityTestDiv ) { visibilityTestDiv.parentNode.removeChild( visibilityTestDiv ); } } function debounce( func, wait, immediate ) { var timeout; return function() { var context = this, args = arguments; var later = function() { timeout = null; if ( !immediate ) func.apply( context, args ); }; var callNow = immediate && !timeout; clearTimeout( timeout ); timeout = setTimeout( later, wait ); if ( callNow ) func.apply( context, args ); }; } const debouncedTriggerPostRender = debounce( function() { triggerPostRender(); }, 200 ); if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) { const observer = new MutationObserver( ( mutations ) => { mutations.forEach( ( mutation ) => { if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) { debouncedTriggerPostRender(); observer.disconnect(); } }); }); observer.observe( document.body, { attributes: true, childList: false, subtree: true, attributeFilter: [ 'style', 'class' ], }); } else { triggerPostRender(); } } );} );
|
| 215 |
+
</script>
|
| 216 |
+
</div></div>
|
| 217 |
+
</div>
|
| 218 |
+
</div>
|
| 219 |
+
</div>
|
| 220 |
+
</div>
|
| 221 |
+
</div>
|
| 222 |
+
</div>
|
| 223 |
+
</div>
|
| 224 |
+
</div>
|
| 225 |
+
|
| 226 |
+
<script src="script.js"></script>
|
| 227 |
+
</body>
|
| 228 |
</html>
|