{"id":393,"date":"2018-03-27T14:14:27","date_gmt":"2018-03-27T14:14:27","guid":{"rendered":"https:\/\/azdentalwellness.com\/?page_id=393"},"modified":"2021-10-15T11:04:48","modified_gmt":"2021-10-15T11:04:48","slug":"book-an-appointment","status":"publish","type":"page","link":"https:\/\/azdentalwellness.com\/?page_id=393","title":{"rendered":"Book an Appointment"},"content":{"rendered":"<form id=\"form1506\" onsubmit=\"return AppointmentFormValidate(this);\" name=\"form1506\" method=\"post\" action=\"https:\/\/www.ekwa.com\/ekwa-wufoo-handler\/\" class=\"form-horizontal\">\n\t<div class=\"form-group\">\n\t\t<label for=\"Field24\">Appointment Date *<\/label>\n\t\t<i class=\"fa fa-calendar-o\" aria-hidden=\"true\"><\/i>\n\t\t<input id=\"Field24\" name=\"Field24\" type=\"text\" class=\"form-control datepicker\" placeholder=\"Appointment Date *\" >\n\t<\/div>\n\t<div class=\"form-group\">\n\t\t<label for=\"Field26\">Time <\/label>\n\t\t<i class=\"fa fa-clock-o\" aria-hidden=\"true\"><\/i>\n\t\t<input name=\"Field26\" type=\"text\" class=\"form-control timepicker\" id=\"Field26\" placeholder=\"Time\">\n\t<\/div>\n\t<div class=\"form-group\">\n\t\t<label for=\"Field6\">Your Name * <\/label>\n\t\t<i class=\"fa fa-user\" aria-hidden=\"true\"><\/i>\n\t\t<input name=\"Field6\" type=\"text\" class=\"form-control\" id=\"Field6\" placeholder=\"Your Name * \">\n\t<\/div>\n\t<div class=\"form-group\">\n\t\t<label for=\"Field8\">Contact Number * <\/label>\n\t\t<i class=\"fa fa-phone\" aria-hidden=\"true\"><\/i>\n\t\t<input name=\"Field129\" type=\"text\" class=\"form-control\" id=\"Field129\" placeholder=\"Contact Number *\" maxlength=\"12\">\n\t<\/div>\n\t<div class=\"form-group\">\n\t\t<label for=\"Field10\">Comments * <\/label>\n\t\t<i class=\"fa fa-comments-o\" aria-hidden=\"true\"><\/i>\n\t\t<textarea class=\"form-control\" name=\"Field10\" id=\"Field10\" placeholder=\"Comments *\"><\/textarea>\n\t<\/div>\n\t<div class=\"checkbox\">\n\t\t<label for=\"Field28\"><input id=\"Field28\" name=\"Field28\" type=\"checkbox\" class=\"field checkbox\" value=\"I Accept\" tabindex=\"6\" onchange=\"handleInput(this);\"> By submitting the above form you agree and accept our <a style=\"color: #4C4C4C;\" href=\"https:\/\/www.azdentalwellness.com\/privacy-policy\/\" target=\"_parent\">Privacy Policy<\/a>.*<\/label>\n\t<\/div>\n    <div class=\"lazyload\" data-script=\"https:\/\/www.google.com\/recaptcha\/api.js?onload=renderRecaptcha&render=explicit\"><\/div>\n\t<div id=\"contact-form-captcha\"><\/div>\n\t<div class=\"form-group\">\n\t\t<button type=\"submit\" class=\"btn btn-default\">Submit<\/button>\n\t<\/div>\n\t<input type=\"hidden\" name=\"url\" value=\"https:\/\/salesmanager.wufoo.com\/forms\/z1ntjstd0g5db6s\/#public\">\n\t<input type=\"hidden\" id=\"idstamp\" name=\"idstamp\" value=\"K0zuTPZWUVY2h6zHH68gQWsC5rEklC53esbaClxieB8=\" \/>\n<\/form>\n\n<style>\n\t\n.form-bg{ background: #ddd; }\n.form-horizontal{\n\tbackground: #fff;\n\tpadding: 80px 50px;\n}\n.form-horizontal .form-group{\n\tmargin: 0 0 30px 0;\n\tposition: relative;\n}\n.form-horizontal .form-group:last-child{ margin: 40px 0 0 0; }\n.form-horizontal .form-group i{\n\twidth: 50px;\n\theight: 50px;\n\tline-height: 50px;\n\tfont-size: 18px;\n\tcolor: #c4c4c4;\n\ttext-align: center;\n\tposition: absolute;\n\ttop: 0;\n\tleft: 0;\n\tz-index: 1;\n}\n.form-horizontal .form-control{\n\theight: 50px;\n    width: 100%;\n\tbackground: #fff;\n\tborder: 2px solid #d9d9d9;\n\tbox-shadow: none;\n\tpadding: 0 20px 0 50px;\n\tfont-size: 16px;\n\tcolor: #7f8291;\n\tposition: relative;\n\ttransition: all 0.3s ease 0s;\n}\n.form-horizontal textarea.form-control{\n\tpadding-top: 10px;\n\theight: 80px;\n} \n.form-horizontal .form-control[type=password]{ padding: 0 105px 0 50px; }\n.form-horizontal .form-control:focus{\n\tbox-shadow: none;\n\toutline: 0 none;\n\tborder-color: #4b92e3;\n}\n.form-horizontal .form-control::-webkit-input-placeholder,\n.form-horizontal .form-control::-moz-placeholder,\n.form-horizontal .form-control::placeholder{ color: #c4c4c4; }\n.form-horizontal .form-group label{\n\tpadding: 0 7px;\n\tdisplay: none;\n\tbackground: #4b92e3;\n\tfont-size: 14px;\n\tcolor: #fff;\n\tletter-spacing: 0.5px;\n\tmargin-bottom: 10px;\n\tborder-radius: 3px;\n\topacity: 0;\n\tz-index: 1;\n\tposition: absolute;\n\ttop: -9px;\n\tleft: 15px;\n\ttransition: all 0.3s ease 0s;\n}\n.form-horizontal .form-group:hover label{\n\topacity: 0;\n\ttop: -9px;\n}\n\n.form-horizontal .signup{\n\tdisplay: inline-block;\n\tfont-size: 16px;\n\tcolor: #8f8f8f;\n\ttext-transform: capitalize;\n\tmargin-top: 8px;\n}\n.form-horizontal .signup a{ color: #4b92e3; }\n.form-horizontal .btn{\n\tpadding: 8px 30px;\n\tbackground: #5f5f5f;\n\tborder: 3px solid #5f5f5f;\n\tfont-size: 16px;\n\tfont-weight: bold;\n\tcolor: #fff;\n\tborder-radius: 0;\n\ttext-transform: uppercase;\n\tmargin-top: 20px;\n}\n.form-horizontal .btn:hover{\n\tbackground: #fff;\n\tcolor: #5f5f5f;\n}\n.form-horizontal .btn:focus{\n\tbackground: #4b92e3;\n\tcolor: #fff;\n}\n@media only screen and (max-width: 479px){\n\t.form-horizontal{ padding: 40px 20px; }\n\t.form-horizontal .form-group:last-child{\n\t\ttext-align: center;\n\t\tmargin-top: 0;\n\t}\n\t.form-horizontal .signup{\n\t\tdisplay: block;\n\t\tmargin-bottom: 10px;\n\t}\n\t.form-horizontal .btn{ float: none; }\n}\n<\/style>\n\n<script>\n \/*============== Appointment Request Form Validation START =================*\/\nfunction AppointmentFormValidate(theForm) {\n    var reason = \"\";\n\treason += validateDate(theForm.Field24);\n    reason += validateName(theForm.Field6);\n    reason += validateTel(theForm.Field129);\n    reason += validateMessage(theForm.Field10);\n  \/\/  reason += validateQuestion(theForm.question);\n  reason += validateConfirm(theForm.Field28);\n  reason += validateCaptcha(contactFormCaptcha);\n\n    if (reason != \"\") {\n        alert(\"Following field(s) need to be Filled:\\n\" + reason);\n        return false;\n    }\n    if(checkValue(theForm)) {\n        insitePost(theForm);\n    }\n    setTimeout(function(){theForm.submit();},500); \/\/ increase this value if it's not tracking properly\n    return true;\n}\n\nfunction validateConfirm(fld) {\n    var error = \"\";\n    if (fld.checked == \"\") {\n        fld.style.background = \"\";\n        error = \"- Please accept our privacy policy\\n\"\n    }\n    return error;\n}\n\n\nfunction validateDate(fld) {\n    var error = \"\";\n\n    if (fld.value == \"\") {\n        fld.style.background = \"\";\n        error = \"- Enter a date\\n\"\n    } else if (fld.value == \"Appointment Date*\") {\n        fld.style.background = \"\";\n        error = \"- Enter a date\\n\"\n    } else {\n        fld.style.background = \"\";\n    }\n    return error;\n}\n\nfunction validateTime(fld) {\n    var error = \"\";\n\n    if (fld.value == \"\") {\n        fld.style.background = \"\";\n        error = \"- Enter a date\\n\"\n    } else if (fld.value == \"Time\") {\n        fld.style.background = \"\";\n        error = \"- Select a Time\\n\"\n    } else {\n        fld.style.background = \"\";\n    }\n    return error;\n}\n\nfunction validateName(fld) {\n    var error = \"\";\n\n    if (fld.value == \"\") {\n        fld.style.background = \"\";\n        error = \"- Enter your name\\n\"\n    } else if (fld.value == \"Your Name *\") {\n        fld.style.background = \"\";\n        error = \"- Enter your name\\n\"\n    } else {\n        fld.style.background = \"\";\n    }\n    return error;\n}\n\nfunction trim(s)\n{\n    return s.replace(\/^\\s+|\\s+$\/, '');\n}\n\nfunction validateEmail(fld) {\n    var error=\"\";\n    var tfld = trim(fld.value);                        \/\/ value of field with whitespace trimmed off\n    var emailFilter = \/^[^@]+@[^@.]+\\.[^@]*\\w\\w$\/ ;\n\n    if (fld.value == \"\") {\n        fld.style.background = \"\";\n        error = \"- Enter your email address\\n\";\n    } else if (!emailFilter.test(tfld)) {              \/\/test email address for illegal characters\n        fld.style.background = \"\";\n        error = \"- Enter a valid email address\\n\";\n    } else if (fld.value == \"Email Address *\") {              \/\/test email address for illegal characters\n        fld.style.background = \"\";\n        error = \"- Enter a valid email address\\n\";\n    } else {\n        fld.style.background = \"\";\n    }\n    return error;\n}\n\nfunction isNumeric(v) {\n    return v.length > 0 && !isNaN(v) && v.search(\/[A-Z]|[#]\/ig) == -1;\n};\n\nvar tele = document.querySelector('#Field129');\ntele.addEventListener('keyup', function(e){\n  if (event.key != 'Backspace' && (tele.value.length === 3 || tele.value.length === 7)){\n  tele.value += '-';\n  }\n});\n\nfunction validateTel(fld) {\n    var error = \"\";\n    var stripped = fld.value.replace(\/[\\(\\)\\.\\-\\ ]\/g, '');\n\t\n    if (stripped == \"\") {\n        error = \"- Enter your telephone number \\n\";\n        fld.style.color =\"\";\n    }\n    else if(stripped.length != 10){\n\t\terror = \"- Enter valid telephone number \\n\";\n    }\n    else if(stripped == \"Your Contact Number *\"){\n\t\terror = \"- Enter your telephone number \\n\";\n    }\n    else {\n        if (isNumeric(stripped) == false) {\n            error = \"- Enter only numeric values for your telephone number \\n\";\n        }\n        else{\n            fld.style.color =\"\";\n        }\n    }\n    return error;\n}\n\nfunction validateMessage(fld) {\n    var error = \"\";\n\n    if (fld.value == \"\") {\n        fld.style.background = \"\";\n        error = \"- Enter other specific requests\/comments\\n\"\n    } else if (fld.value == \"Comments *\"){\n        fld.style.background = \"\";\n        error = \"- Enter other specific requests\/comments\\n\"\n    } else {\n        fld.style.background = \"\";\n    }\n    return error;\n}\n\nfunction validateQuestion(fld){\n    var error = \"\";\n\n    if (fld.value == \"\") {\n        fld.style.background = \"\";\n        error = \"- Answer the simple question\\n\";\n    } else {\n        fld.style.background = \"\";\n    }\n    return error;\n}\n\nfunction validateCaptcha(fld) {\n    var error = \"\";\n    if (grecaptcha.getResponse(fld) == \"\") {\n        error = \"- Please confirm you are not a robot\\n\"\n    }\n    return error;\n}\nshowBackEndSuccess('rel');\n\nfunction showBackEndSuccess(uriSer) {\n    if (getUrlParameter(uriSer) && \/thank-you\/.test(getUrlParameter(uriSer))) {\n        setTimeout(function () {\n            alert(\n                'Successfully submitted. We ensure that we will get back to you as soon as possible during working hours.');\n        }, 2000);\n    }\n}\nshowBackEndError('form-error', 'error-elm');\n\nfunction showBackEndError(uriSer, uriElm) {\n    if (getUrlParameter(uriSer)) {\n        var elemStr = getUrlParameter(uriElm);\n        var tempElem = null;\n        if (elemStr != \"\") {\n            tempElem = document.querySelector('#' + getUrlParameter(uriElm));\n        }\n        if (tempElem) {\n            tempElem.style.borderColor = 'red';\n            tempElem.style.borderWidth = '1px';\n            tempElem.style.borderStyle = 'solid';\n            tempElem.focus();\n        }\n        setTimeout(function () {\n            alert(getUrlParameter(uriSer));\n        }, 2000);\n        if (getUrlParameter('form-data')) {\n            var formDataObj = JSON.parse(atob(getUrlParameter('form-data')))\n            var formDataKeyArr = Object.keys(formDataObj);\n            for (var i = 0; i < formDataKeyArr.length; i++) {\n                if (document.getElementById(formDataKeyArr[i])) {\n                    document.getElementById(formDataKeyArr[i]).value = formDataObj[formDataKeyArr[i]];\n                }\n\n            }\n        }\n    }\n}\n\nfunction getUrlParameter(name) {\n    name = name.replace(\/[\\[]\/, '\\\\[').replace(\/[\\]]\/, '\\\\]');\n    var regex = new RegExp('[\\\\?&]' + name + '=([^&#]*)');\n    var results = regex.exec(location.search);\n    return results === null ? 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