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getTheActualForm.php
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getTheActualForm.php
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<?php
function getTheActualForm() {
if ( is_user_logged_in() ){
include_once('loadFieldValuesIntoForm.php');
loadFieldValuesIntoForm();
}
$shortCodeOutput = <<<SCO_HEREDOC
<!--Stylesheet-->
<link rel='stylesheet' href='//code.jquery.com/ui/1.11.4/themes/smoothness/jquery-ui.css'>
<link rel='stylesheet' href='https://maxcdn.bootstrapcdn.com/bootstrap/3.3.5/css/bootstrap.min.css'>
<!--Scripts-->
<script src='//code.jquery.com/jquery-1.10.2.js'></script>
<script src='//code.jquery.com/ui/1.11.4/jquery-ui.js'></script>
<script src='https://maxcdn.bootstrapcdn.com/bootstrap/3.3.5/js/bootstrap.min.js'></script>
<!--Style-->
<style>
h3 {
color: darkcyan;
}
h4
{
padding:5px;
background-color: darkseagreen;
border-radius: 5px;
}
.input-group-lg > .form-control,
.input-group-lg > .input-group-addon,
.input-group-lg > .input-group-btn > .btn {
height: 45px;
padding: 10px 16px;
font-size: 18px;
line-height: 1.33;
border-radius: 6px;
}
.input-group .form-control {
z-index:1;
}
.ui-datepicker {
width: 19em;
}
.personal_info {
background-color: powderblue;
border-radius: 5px;
}
select option {
color: black;
padding-left: 10px;
}
.empty {
color: #999;
padding-left: 8px;
}
.submit {
background-color: darkseagreen;
font-size: 16px;
}
</style>
<script>
$(function () {
$('#date-of-birth').datepicker({
changeMonth: true,
changeYear: true,
yearRange: "1900:2010"
});
$('#infusion-start-date').datepicker({
changeMonth: true,
changeYear: true,
maxDate: "+5y",
minDate: new Date()
});
$("select").change(function () {
if ($(this).val() === "0")
$(this).addClass("empty");
else
$(this).removeClass("empty")
});
$("select").change();
});
</script>
<!--Form-->
<div class='container'>
<h3>Arctic Cold Cap Therapy</h3>
<p>Please complete the form below and a Arctic Cold Caps representative will call to get you started. Please fill out all the information you know. Call us if you have any questions or concerns.</p>
<!--Column-->
<form method = 'post' class='form-vertical' name = "CRG-InfoForm" action = "/services/" >
<input type = "hidden" name = "crg-info-form" value = "TRUE" />
<div class='col-sm-12 personal_info'>
<h4 class="text-center">Personal Information</h4>
<fieldset class="col-sm-6">
<div class='form-group'>
<label class='control-label'>Name:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-user'></i></span>
<input placeholder='Your first name' name='First_Name' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-user'></i></span>
<input placeholder='Your last name' name='Last_Name' type='text' class='form-control'>
</div>
</div>
<div class='form-group'>
<label class='control-label'>Date of Birth:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-user'></i></span>
<input id = 'date-of-birth' type='text' name = 'date-of-birth' type = 'text' placeholder='Your Date of Birth' class='form-control'>
</div>
</div>
<div class='form-group'>
<label class='control-label'>Contact Information:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-envelope'></i></span>
<input placeholder='Your email address' name='crg_login_email' type='email' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-phone-alt'></i></span>
<input placeholder='Your land phone number' name='Phone' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-phone-alt'></i></span>
<input placeholder='Your mobile phone number' name='Mobile' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-phone-alt'></i></span>
<input placeholder='Your fax number' name='Fax' type='text' class='form-control'>
</div>
</div>
</fieldset>
<fieldset class="col-sm-6">
<div class='form-group'>
<label class='control-label'>Mailing Address:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Your mailing street address' name='Address' type='text' class='form-control'/>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Your mailing city' name='City' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<select class='empty form-control' name = "State" style="padding-left:8px;">
<option value="0" selected="selected">Your mailing state</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Your mailing zip' name='Zip' type='text' class='form-control'>
</div>
</div>
<div class='form-group'>
<label class='control-label'>Spouse / Relative Information:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-user'></i></span>
<input placeholder="Spouse / Relative's Name" name='Spouse-Relative' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-phone-alt'></i></span>
<input placeholder= "Spouse / Relative's Phone Number" name='Spouse-Relative-Phone' type='text' class='form-control'>
</div>
</fieldset>
<fieldset class="col-sm-12">
<div class='form-group'>
<label class='control-label'>Notes:</label>
<textarea class="form-control" name = "notes" style = "width:100%; height:10em;"></textarea>
</div>
</fieldset>
</div><!--Column-->
<div class="divider"> </div>
<div class='col-sm-12 personal_info'>
<h4 class="text-center">Cancer Details</h4>
<fieldset class="col-sm-6">
<div class='form-group'>
<div class='form-group col-sm-12'>
<label class='control-label'>Diagnosis:</label>
<textarea name = "diagnosis"></textarea>
</div>
<div class="col-sm-8 text-right" style="padding-right:5px;">
<label class='control-label'>Regimen:</label>
</div>
<div class="col-sm-4" style="padding-left:0;">
<select class="form-control" name = "regimen" style="padding-left:8px;">
<option value="AC">AC</option>
<option value="ACT">ACT</option>
<option value="FEC">FEC</option>
<option value="TC">TC</option>
<option value="TCH">TCH</option>
<option value="Other" selected="selected">Other</option>
</select>
</div>
</div>
<div class="divider"> </div>
<div class='form-group'>
<div class="col-sm-8 text-right" style="padding-right:5px;">
<label class='control-label'>When is your infusion scheduled to begin? :</label>
</div>
<div class="col-sm-4" style="padding-left:0;">
<input name = "Infusion_Start_Date" id = "infusion-start-date" type = "text" class="form-control" placeholder = "Date" />
</div>
</div>
<div class="divider"> </div>
<div class='form-group'>
<div class="col-sm-8 text-right" style="padding-right:5px;">
<label class='control-label'>How many weeks apart are your treatments? :</label>
</div>
<div class="col-sm-4" style="padding-left:0;">
<input name = "Weeks_Apart" id = "infusion-weeks-apart" type = "text" class="form-control" placeholder = "A number" />
</div>
</div>
<div class="divider"> </div>
<div class='form-group'>
<div class="col-sm-8 text-right" style="padding-right:5px;">
<label class='control-label'>How many rounds are you scheduled for? :</label>
</div>
<div class="col-sm-4" style="padding-left:0;">
<input name = "Number_Of_Rounds" type = "text" class="form-control" placeholder = "A number" />
</div>
</div>
<div class="divider"> </div>
<div class='form-group col-sm-12'>
<label class='control-label'>Oncologist Name:</label>
<input placeholder='Your oncologist name' name='Oncologist_Name' type='text' class='form-control'>
</div>
<div class='form-group col-sm-12'>
<label class='control-label'>Oncologist Phone Number:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-phone-alt'></i></span>
<input placeholder='Your oncologist phone number' name='Oncologist_Phone' type='text' class='form-control'>
</div>
</div>
</fieldset>
<fieldset class="col-sm-6">
<div class='form-group'>
<label class='control-label'>Oncologist Mailing Address:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Street Address' name='Oncologist_Address' type='text' class='form-control'>
</div>
<!--<label class='control-label'>City:</label>-->
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='City' name='Oncologist_City' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<select class="empty form-control" name = "Oncologist_State" style="padding-left:8px;">
<option value="0" selected="selected">State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Zip' name='Oncologist_Zip' type='text' class='form-control'>
</div>
</div>
<div class='form-group'>
<label class='control-label'>Oncology Treatment Center:</label>
<input placeholder='Your oncology treatment center' name='Oncology_Treatment_Center' type='text' class='form-control'>
</div>
<div class='form-group'>
<label class='control-label'>Treatment Center Mailing Address:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Street Address' name='Treatment_Address' type='text' class='form-control'/>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='City' name='Treatment_City' type='text' class='form-control'>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<select class="empty form-control" name = "Treatment_State" style="padding-left:8px;">
<option value="0" selected="selected">State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</div>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Zip' name='Treatment_Zip' type='text' class='form-control'>
</div>
</div>
<div class='form-group'>
<label class='control-label'>Nurse Navigator:</label>
<div class='input-group'>
<span class='input-group-addon'><i class='glyphicon glyphicon-map-marker'></i></span>
<input placeholder='Name' name='nurse_navigator_name' type='text' class='form-control'/>
<input placeholder='Telephone Number' name='nurse_navigator_phone' type='text' class='form-control'/>
</div>
</div>
</fieldset>
</div><!--Column-->
<div class="divider"> </div>
<input type = "hidden" name = "UserID" />
<div class='form-group'>
<div class='button text-center'>
<input type='submit' value="Submit" class='btn submit'>
</div>
</div>
</form>
</div><!--Container-->
SCO_HEREDOC;
return $shortCodeOutput;
}
?>