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| <!DOCTYPE html> | |
| <html> | |
| <head> | |
| <meta http-equiv="Content-Type" content="text/html; charset=utf-8"> | |
| <meta name="viewport" content="width=device-width, initial-scale=1.0"> | |
| <title>Marketing Form</title> | |
| <meta name="referrer" content="never"> | |
| <meta type="xrm/designer/setting" name="type" value="marketing-designer-content-editor-document"> | |
| <meta type="xrm/designer/setting" name="layout-editable" value="marketing-designer-layout-editable"> | |
| <style> | |
| div[data-editorblocktype="Captcha"] td:nth-of-type(2) a { | |
| text-decoration: none; | |
| font-family: "Segoe UI", Arial, sans-serif; | |
| font-size: 14px; | |
| } | |
| [data-layout="true"] { | |
| margin: 0 auto; | |
| max-width: 600px; | |
| background-color: rgba(255, 255, 255, 0); | |
| } | |
| div[data-editorblocktype="Captcha"] table, | |
| div[data-editorblocktype="Captcha"] div > table > tbody > tr > td:nth-of-type(2) { | |
| width: 100% !important; | |
| } | |
| div[data-editorblocktype="Captcha"] div > div > table > tbody > tr:first-of-type > td:last-of-type { | |
| padding-bottom: 12px !important; | |
| } | |
| div[data-editorblocktype="Captcha"] tr[id="wlspispHIPErrorContainer"] { | |
| margin-top: 20px; | |
| } | |
| div[data-editorblocktype="Captcha"] tr[id="wlspispHIPErrorContainer"] td:nth-of-type(2) { | |
| width: auto !important; | |
| } | |
| div[data-editorblocktype="Captcha"] tr[id="wlspispHIPErrorContainer"] img { | |
| display: flex; | |
| } | |
| div[data-editorblocktype="Captcha"] td:nth-of-type(2) > div > div { | |
| margin-top: 4px; | |
| } | |
| div[data-editorblocktype="Captcha"] td:nth-of-type(2) > div > div * { | |
| font-weight: 400; | |
| } | |
| div[data-editorblocktype="Captcha"] td:nth-of-type(2) > div > div b { | |
| color: #797775; | |
| } | |
| div[data-editorblocktype="Captcha"] tr:nth-of-type(2) > td { | |
| height: 0px !important; | |
| } | |
| div[data-editorblocktype="Captcha"] td input { | |
| margin-top: 20px !important; | |
| padding: 6px 8px !important; | |
| width: 100% !important; | |
| } | |
| div[data-editorblocktype="Captcha"] div[id^="wlspaudioBtnHolder"] { | |
| display: flex; | |
| align-items: center; | |
| justify-content: center; | |
| } | |
| .textFormFieldBlock label::after, | |
| .twooption_checkbox label::after, | |
| .dateTimeFormFieldBlock label::after, | |
| .lookupFormFieldBlock label::after, | |
| .twoOptionFormFieldBlock label.block-label::after, | |
| .twoOptionFormFieldBlock div.twooption_checkbox label::after, | |
| .optionSetFormFieldBlock label.block-label::after, | |
| .multiOptionSetFormFieldBlock label.block-label::after, | |
| .consentBlock label p:first-of-type::after, | |
| .eventSession label::after, | |
| div[data-editorblocktype="Captcha"] label[id^="wlspispHipInstructionContainer"]::after { | |
| width: 22px; | |
| display: inline-block; | |
| line-height: 22px; | |
| text-align: center; | |
| color: #c33400; | |
| content: "*"; | |
| visibility: hidden; | |
| } | |
| div[data-required].textFormFieldBlock label::after, | |
| div[data-required].dateTimeFormFieldBlock label::after, | |
| div[data-required].lookupFormFieldBlock label::after, | |
| div[data-required] div.twooption_checkbox label::after, | |
| div[data-required] label.block-label::after, | |
| div[data-required="true"].consentBlock label p:first-of-type::after, | |
| div[data-editorblocktype="Captcha"] label[id^="wlspispHipInstructionContainer"]::after { | |
| visibility: visible; | |
| } | |
| div[data-hide].textFormFieldBlock, | |
| div[data-hide].dateTimeFormFieldBlock, | |
| div[data-hide].lookupFormFieldBlock, | |
| div[data-hide].twoOptionFormFieldBlock, | |
| div[data-hide].optionSetFormFieldBlock, | |
| div[data-hide].multiOptionSetFormFieldBlock { | |
| background-image: url(data\003a image/svg+xml\003b base64,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); | |
| background-repeat: no-repeat; | |
| background-size: 16px 16px; | |
| background-position-x: 95%; | |
| background-position-y: 28%; | |
| } | |
| .multiOptionSetFormFieldBlock fieldset > div > label { | |
| font-weight: 400; | |
| font-size: 14px; | |
| line-height: 20px; | |
| } | |
| .twoOptionFormFieldBlock div.radiobuttons, | |
| .optionSetFormFieldBlock div.radiobuttons { | |
| padding: 0px; | |
| margin: 0px; | |
| border-radius: 0px; | |
| } | |
| .twoOptionFormFieldBlock div.twooption_checkbox > div, .consentBlock > div { | |
| width: 100%; | |
| border-radius: 0px; | |
| } | |
| .twoOptionFormFieldBlock div.radiobuttons div, | |
| .optionSetFormFieldBlock div.radiobuttons div { | |
| width: 100%; | |
| } | |
| .twoOptionFormFieldBlock div.twooption_checkbox div, | |
| .consentBlock div { | |
| padding: 0px; | |
| margin: 0px; | |
| } | |
| .eventSessions { | |
| font-size: 16px; | |
| line-height: 1.2; | |
| border: none | |
| } | |
| .eventSession label b { | |
| display:inline | |
| } | |
| .eventSession > div > input[type="checkbox"] { | |
| float: right; | |
| } | |
| .dividerWrapper p span { | |
| line-height: 0px; | |
| } | |
| .notification-container { | |
| margin-left: 10px; | |
| margin-right: 10px; | |
| margin-bottom: 10px; | |
| margin-top: 10px; | |
| } | |
| .notification-message { | |
| display: flex; | |
| justify-content: center; | |
| align-items: center; | |
| min-height: 38px; | |
| border: 1.44737px solid#CCCCCC; | |
| border-radius: 10px; | |
| margin-bottom: 10px; | |
| margin-top: 10px; | |
| } | |
| .notification-message-hide { | |
| display: none; | |
| } | |
| div[data-required].phoneFormFieldBlock label::after { | |
| visibility: visible; | |
| } | |
| div[data-hide].phoneFormFieldBlock { | |
| background-image: url(data\003a image/svg+xml\003b base64,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); | |
| background-repeat: no-repeat; | |
| background-size: 16px 16px; | |
| background-position-x: 95%; | |
| background-position-y: 28%; | |
| } | |
| .phoneFormFieldBlock .phoneCountryCode { | |
| display: flex; | |
| flex: 2 1 20%; | |
| align-items: center; | |
| flex-direction: row; | |
| box-sizing: border-box; | |
| border: 1px solid #e1dfdd; | |
| border-radius: 2px; | |
| justify-content: center; | |
| background-color: transparent; | |
| overflow: hidden; | |
| width: 100%; | |
| height: 100%; | |
| } | |
| .phoneFormFieldBlock .phoneCountryCodeLabel { | |
| overflow: hidden; | |
| margin: 0; | |
| cursor: pointer; | |
| padding-left: 5px; | |
| padding-right: 5px; | |
| opacity: 1; | |
| text-align: center; | |
| color: #605E5C; | |
| background-color: #F3F2F1; | |
| align-items: center; | |
| align-self: stretch; | |
| display: flex; | |
| } | |
| .phoneFormFieldBlock span[hidden] { | |
| display: none; | |
| } | |
| </style> | |
| </head> | |
| <body> | |
| <form class="cwh-form cwh-form--marketing-form"> | |
| <div data-layout="true" data-layout-version="v2"> | |
| <div class="notification-container"> | |
| <div class="notification-message notification-message-hide" data-notification-name="eventNotStarted"> | |
| <div>This event has not started.</div> | |
| </div> | |
| <div class="notification-message notification-message-hide" data-notification-name="eventAtCapacity"> | |
| <div>This event is fully booked</div> | |
| </div> | |
| <div class="notification-message notification-message-hide" data-notification-name="eventEnded"> | |
| <div>This event has ended.</div> | |
| </div> | |
| </div> | |
| <div data-section="true" class="emptyContainer columns-equal-class wrap-section"> | |
| <div class="textFormFieldBlock half-width" data-editorblocktype="TextFormField" data-targetproperty="firstname" data-required="required"> | |
| <label title="First Name" for="firstname-1721674430878"> | |
| <span> | |
| First Name | |
| </span> | |
| </label> | |
| <input | |
| id="firstname-1721674430878" | |
| type="text" | |
| name="firstname" | |
| placeholder="First Name" | |
| title="First Name" | |
| maxlength="50" | |
| required="required"> | |
| </div> | |
| <div class="textFormFieldBlock half-width" data-editorblocktype="TextFormField" data-targetproperty="lastname" data-required="required"> | |
| <label title="Last Name" for="lastname-1721674437182"> | |
| <span> | |
| Last Name | |
| </span> | |
| </label> | |
| <input | |
| id="lastname-1721674437182" | |
| type="text" | |
| name="lastname" | |
| placeholder="Last Name" | |
| title="Last Name" | |
| maxlength="50" | |
| required=""> | |
| </div> | |
| <div class="textFormFieldBlock half-width" data-editorblocktype="TextFormField" data-targetproperty="emailaddress1" data-required="required"> | |
| <label title="Email" for="emailaddress1-1721674447788"> | |
| <span> | |
| </span> | |
| </label> | |
| <input | |
| id="emailaddress1-1721674447788" | |
| type="email" | |
| name="emailaddress1" | |
| placeholder="Email" | |
| title="Email" | |
| pattern="[^@\\s\"<>\\)\\(\\[\\]:;,.]+((\\.[^@\\s\"<>\\)\\(\\[\\]:;,.]+)+?|)@([^@\\s\"<>\\)\\(\\[\\]+:;.,-]+((\\.|\+|-|--)[^@\\s\"<>\\)\\(\\[\\]+:;.,-]+)+?|)(\\.[^0-9@\\s\"<>\\)\\(\\[\\]+:;.,-]+)+?)" | |
| required="required"> | |
| </div> | |
| <div class="phoneFormFieldBlock half-width" data-editorblocktype="PhoneFormField" data-targetproperty="address1_telephone1" data-countrycode="+"> | |
| <label for="address1_telephone1-1721674459149" title="Address 1: Telephone 1"> | |
| <span> | |
| Phone | |
| </span> | |
| </label> | |
| <div class="phoneCountryCode"> | |
| <span class="phoneCountryCodeLabel" hidden=""> | |
| + | |
| </span> | |
| <input | |
| id="address1_telephone1-1721674459149" | |
| type="tel" | |
| name="address1_telephone1" | |
| placeholder="Phone" | |
| title="Phone" | |
| > | |
| </div> | |
| </div> | |
| <div class="textFormFieldBlock half-width" data-editorblocktype="TextFormField" data-targetproperty="companyname" data-required="required"> | |
| <label title="Company Name" for="companyname-1721674467693"> | |
| <span> | |
| Company | |
| </span> | |
| </label> | |
| <input | |
| id="companyname-1721674467693" | |
| type="text" | |
| name="companyname" | |
| placeholder="Company Name" | |
| title="Company Name" | |
| maxlength="100" | |
| required="required"> | |
| </div> | |
| <div class="textFormFieldBlock half-width" data-editorblocktype="TextFormField" data-targetproperty="jobtitle"> | |
| <label title="Job Title" for="jobtitle-1721674473507"> | |
| <span> | |
| Title | |
| </span> | |
| </label> | |
| <input id="jobtitle-1721674473507" type="text" name="jobtitle" placeholder="Job Title" title="Job Title" maxlength="100"> | |
| </div> | |
| </div> | |
| <div data-section="true" class="emptyContainer columns-equal-class wrap-section" style="margin: 0px; border-radius: 0px;"> | |
| <div class="optionSetFormFieldBlock" data-editorblocktype="OptionSetFormField" data-targetproperty="cwh_healthcaresegmentcode"> | |
| <label title="Healthcare Segment" class="block-label" for="cwh_healthcaresegmentcode-1721674482630"> | |
| <span> | |
| Healthcare Segment | |
| </span> | |
| </label> | |
| <select id="cwh_healthcaresegmentcode-1721674482630" name="cwh_healthcaresegmentcode" title="Healthcare Segment"> | |
| <option value="" hidden=""> | |
| -- Choose One -- | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560000" value="771560000"> | |
| Payer | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560001" value="771560001"> | |
| Provider | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560002" value="771560002"> | |
| Payvider | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560003" value="771560003"> | |
| Technology Company | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560004" value="771560004"> | |
| Services Company | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560005" value="771560005"> | |
| Tech/Services Vendor | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560006" value="771560006"> | |
| Government | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560007" value="771560007"> | |
| Med Dev/Pharma | |
| </option> | |
| <option id="cwh_healthcaresegmentcode-1721674482630-771560008" value="771560008"> | |
| Association | |
| </option> | |
| </select> | |
| </div> | |
| <div class="textFormFieldBlock" data-editorblocktype="TextFormField" data-targetproperty="subject" data-hide="hide"> | |
| <label title="Topic" aria-label="null" for="subject-1721674535810"> | |
| <div id="editorIdPrefixd6e2c11f9ff2b1722535748568" aria-readonly="false" tabindex="0" spellcheck="true" aria-multiline="true" aria-describedby="cke_146" aria-controls="cke_147" aria-activedescendant="" aria-autocomplete="list" aria-expanded="false" style="margin-top: 0px;"> | |
| <span> | |
| Subject | |
| </span> | |
| </div> | |
| </label> | |
| <input | |
| id="subject-1721674535810" | |
| type="text" | |
| name="subject" | |
| placeholder="Topic" | |
| title="Topic" | |
| maxlength="300" | |
| value="Contact Us Form Submission"> | |
| </div> | |
| <div class="textFormFieldBlock" data-editorblocktype="TextAreaFormField" data-targetproperty="description"> | |
| <label title="Description" for="description-1721674559919"> | |
| <span> | |
| Message | |
| </span> | |
| </label> | |
| <textarea | |
| id="description-1721674559919" | |
| name="description" | |
| placeholder="Description" | |
| title="Description" | |
| cols="20" | |
| rows="5" | |
| maxlength="2098"></textarea> | |
| </div> | |
| <div data-editorblocktype="SubmitButton" class="submitButtonWrapper"> | |
| <button class="submitButton" type="submit" aria-label="Let's Connect"> | |
| <span> | |
| Let's Connect | |
| </span> | |
| </button> | |
| </div> | |
| </div> | |
| </div> | |
| </form> | |
| </body> | |
| </html> |
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