Empire Vein – GAE LP English
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font-size: 15px;
font-weight: normal;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
min-width: 128px;
}
li[data-type="control_image"] div {
text-align: left;
}
li[data-type="control_image"] img {
border: none;
border-width: 0px !important;
border-style: solid !important;
border-color: false !important;
}
.supernova {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-attachment: fixed;
background-size: auto;
background-size: cover;
}
.supernova {
background-image: none;
}
#stage {
background-image: none;
}
/* | */
.form-all {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
background-size: cover;
}
.form-header-group {
background-repeat: no-repeat;
background-attachment: scroll;
background-position: center top;
}
.header-large h1.form-header {
font-size: 2em;
}
.header-large h2.form-header {
font-size: 1.5em;
}
.header-large h3.form-header {
font-size: 1.17em;
}
.header-large h1 + .form-subHeader {
font-size: 1em;
}
.header-large h2 + .form-subHeader {
font-size: .875em;
}
.header-large h3 + .form-subHeader {
font-size: .75em;
}
.header-default h1.form-header {
font-size: 2em;
}
.header-default h2.form-header {
font-size: 1.5em;
}
.header-default h3.form-header {
font-size: 1.17em;
}
.header-default h1 + .form-subHeader {
font-size: 1em;
}
.header-default h2 + .form-subHeader {
font-size: .875em;
}
.header-default h3 + .form-subHeader {
font-size: .75em;
}
.header-small h1.form-header {
font-size: 2em;
}
.header-small h2.form-header {
font-size: 1.5em;
}
.header-small h3.form-header {
font-size: 1.17em;
}
.header-small h1 + .form-subHeader {
font-size: 1em;
}
.header-small h2 + .form-subHeader {
font-size: .875em;
}
.header-small h3 + .form-subHeader {
font-size: .75em;
}
.form-header-group {
text-align: left;
}
div.form-header-group.header-large,
div.form-header-group.hasImage {
margin: 0px -38px;
}
div.form-header-group.header-large,
div.form-header-group.hasImage {
padding: 40px 52px;
}
.form-header-group .form-header,
.form-header-group .form-subHeader {
color: -1;
}
.form-line-error {
background-color: rgba(195, 202, 216, 0.3);
box-shadow: inset 0px 3px 11px -7px rgba(255, 255, 255, 0);
}
.form-line-error input:not(#coupon-input),
.form-line-error textarea,
.form-line-error .form-validation-error {
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
border: 1px solid rgba(255, 255, 255, 0);
box-shadow: 0 0 3px rgba(255, 255, 255, 0);
}
.form-line-error .form-error-message {
margin: 0;
position: absolute;
color: #fff;
display: inline-block;
right: 0;
font-size: 12px;
position: absolute!important;
box-shadow: none;
top: 0px;
color: #FFF;
background: rgba(255, 255, 255, 0);
padding: 0px 5px;
bottom: auto;
border-radius: 0;
box-shadow: 0px 2px 4px rgba(102, 102, 102, 0.5);
}
.form-line-error .form-error-message img,
.form-line-error .form-error-message .form-error-arrow {
display: none;
}
.form-line-error {
-webkit-transition-property: none;
-moz-transition-property: none;
-ms-transition-property: none;
-o-transition-property: none;
transition-property: none;
-webkit-transition-duration: 0.3s;
-moz-transition-duration: 0.3s;
-ms-transition-duration: 0.3s;
-o-transition-duration: 0.3s;
transition-duration: 0.3s;
-webkit-transition-timing-function: ease;
-moz-transition-timing-function: ease;
-ms-transition-timing-function: ease;
-o-transition-timing-function: ease;
transition-timing-function: ease;
background-color: rgba(255, 255, 255, 0);
}
.form-line-active {
background-color: rgba(255, 255, 255, 0);
}
/* 29 - FORM COLUMNS */
.form-line-column {
width: calc(100/2 * 1% - 8px);
}
/*__INSPECT_SEPERATOR__*/
.form-buttons-wrapper {
border-top : 0;
margin-bottom : -20px;
}
.form-all {
box-shadow : none !important;
}
.error-navigation-container {
display : none;
}
.form-error-message {
display : none;
}
.form-required {
display : none !important;
}
.form-label {
color : #515459 !important;
}
.form-validation-error {
border : 1px solid #bebebe !important;
}
.form-error-message {
background-color : #ef662f !important;
}
.supernova .form-all, .form-all {
margin-top : 0px !important;
}
/* Injected CSS Code */
</style>
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<ul class="form-section page-section" role="presentation">
<li class="form-line" data-type="control_widget" id="id_5">
<div id="cid_5" class="form-input" data-layout="full">
<div data-widget-name="Liine GUID Injector" style="width:100%;text-align:Left;overflow-x:auto" data-component="widget-field"><iframe data-client-id="ef8be44c2da136d2f81e916e" data-unique-id="" title="Liine GUID Injector" frameBorder="0" scrolling="no" allowtransparency="true" allow="local-network-access *; geolocation; microphone; camera; autoplay; encrypted-media; fullscreen" data-type="iframe" class="custom-field-frame" data-widget-slug="" id="customFieldFrame_5" src="" style="max-width:1px;border:none;width:100%;height:1px" data-width="1" data-height="1"></iframe>
<div class="widget-inputs-wrapper"><input id="input_5" class="form-hidden form-widget " type="hidden" name="q5_typeA5" value="" /><input id="widget_settings_5" class="form-hidden form-widget-settings" type="hidden" data-version="2" value="%5B%5D" /></div>
<script type="text/javascript">
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widgetFrameLoaded(5,
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_cFieldFrame.addClassName("custom-field-frame-rendered");
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else
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_cFieldFrame.classList.add("custom-field-frame-rendered");
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else
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</script>
</div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_textbox" id="id_8"><label class="form-label form-label-top" id="label_8" for="input_8"> First Name *<span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_8" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_8" name="q8_firstName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_8" required="" value="" /> </div>
</li>
<li class="form-line form-line-column form-col-2 jf-required" data-type="control_textbox" id="id_9"><label class="form-label form-label-top" id="label_9" for="input_9"> Last Name *<span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_9" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_9" name="q9_lastName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_9" required="" value="" /> </div>
</li>
<li class="form-line form-line-column form-col-3 jf-required" data-type="control_email" id="id_10"><label class="form-label form-label-top" id="label_10" for="input_10"> Email *<span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_10" class="form-input-wide jf-required" data-layout="half"> <input type="email" id="input_10" name="q10_email" class="form-textbox validate[required, Email]" data-defaultvalue="" autoComplete="section-input_10 email" style="width:310px" size="310" data-component="email" aria-labelledby="label_10" required="" value="" /> </div>
</li>
<li class="form-line form-line-column form-col-4 jf-required" data-type="control_phone" id="id_12"><label class="form-label form-label-top" id="label_12" for="input_12_full"> Phone *<span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_12" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_12_full" name="q12_phoneNumber[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" autoComplete="section-input_12 tel-national" style="width:310px" data-masked="true" placeholder="(000) 000-0000" data-component="phone" aria-label="Phone *" aria-labelledby="label_12 input_12_full_label" required="" value="" /></span><span id="input_12_full_label" style="border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap">Format: (000) 000-0000.</span> </div>
</li>
<li class="form-line jf-required" data-type="control_dropdown" id="id_26"><label class="form-label form-label-top form-label-auto" id="label_26" for="input_26"> Preferred Location *<span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_26" class="form-input-wide jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_26" name="q26_chooseYour" style="width:310px" data-component="dropdown" required="" aria-label="Preferred Location *">
<option value="">Please Select</option>
<option data-calcvalue="Rancho Mirage, CA" value="Rancho Mirage">Rancho Mirage</option>
<option data-calcvalue="Palm Springs, CA" value="Palm Springs">Palm Springs</option>
<option data-calcvalue="La Quinta, CA" value="La Quinta">La Quinta</option>
</select> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_36"><label class="form-label form-label-top form-label-auto" id="label_36" for="input_36"> LIINE LOCATION </label>
<div id="cid_36" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_36" name="q36_liineLocation" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_36" value="" /> </div>
</li>
<li class="form-line always-hidden" data-type="control_dropdown" id="id_13"><label class="form-label form-label-top form-label-auto" id="label_13" for="input_13"> Have You Scheduled An Appointment With Us Before? * </label>
<div id="cid_13" class="form-input-wide always-hidden" data-layout="half"> <select class="form-dropdown" id="input_13" name="q13_haveYou" style="width:310px" data-component="dropdown" aria-label="Have You Scheduled An Appointment With Us Before? *">
<option value="">Please Select</option>
<option data-calcvalue="false" value="Yes - I am an existing patient">Yes - I am an existing patient</option>
<option data-calcvalue="true" value="No - I am a new patient">No - I am a new patient</option>
</select> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_14"><label class="form-label form-label-top form-label-auto" id="label_14" for="input_14"> LIINE IS NEW </label>
<div id="cid_14" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_14" name="q14_isNewText" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_14" value="" /> </div>
</li>
<li class="form-line jf-required" data-type="control_dropdown" id="id_34"><label class="form-label form-label-top form-label-auto" id="label_34" for="input_34"> Preferred Language *<span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_34" class="form-input-wide jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_34" name="q34_preferredLanguage" style="width:310px" data-component="dropdown" required="" aria-label="Preferred Language *">
<option value="">Please Select</option>
<option value="English">English</option>
<option value="Spanish">Spanish</option>
</select> </div>
</li>
<li class="form-line always-hidden" data-type="control_textbox" id="id_33"><label class="form-label form-label-top form-label-auto" id="label_33" for="input_33"> LIINE REDIRECT </label>
<div id="cid_33" class="form-input-wide always-hidden" data-layout="half"> <input type="text" id="input_33" name="q33_liineRedirect" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_33" value="" /> </div>
</li>
<li class="form-line" data-type="control_textarea" id="id_37"><label class="form-label form-label-top form-label-auto" id="label_37" for="input_37"> Message </label>
<div id="cid_37" class="form-input-wide" data-layout="full"> <textarea id="input_37" class="form-textarea" name="q37_message" style="width:648px;height:163px" data-component="textarea" aria-labelledby="label_37"></textarea> </div>
</li>
<li class="form-line jf-required" data-type="control_checkbox" id="id_39"><label class="form-label form-label-top form-label-auto" id="label_39" for="input_39_0"> <span class="form-required" aria-hidden="true">*</span> </label>
<div id="cid_39" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-required="true" aria-labelledby="label_39" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" class="form-checkbox validate[required]" id="input_39_0" name="q39_typeA39[]" aria-labelledby="label_input_39_0" value="<p><span style="color: #666666; font-size: 8pt;">By submitting this form and signing up for texts, you consent to receive text messages related to scheduling your appointment and related promotional offers from Empire Vein at the number provided, and agree that any associated call(s) may be recorded for quality and training purposes. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. The practice will use your personal information in accordance with its privacy policy which can be found here: <a href="https://healthyveins.empirevein.com/privacy-policy/" target="_blank" rel="nofollow">Click for Privacy Policy</a>.</span></p>" /><label aria-hidden="true" id="label_input_39_0" for="input_39_0">
<p><span style="color: #666666; font-size: 8pt;">By submitting this form and signing up for texts, you consent to receive text messages related to scheduling your appointment and related promotional offers from Empire Vein at the number provided, and agree that any associated call(s) may be recorded for quality and training purposes. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. The practice will use your personal information in accordance with its privacy policy which can be found here: <a href="https://healthyveins.empirevein.com/privacy-policy/" target="_blank" rel="nofollow">Click for Privacy Policy</a>.</span></p>
</label></span></div>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_2">
<div id="cid_2" class="form-input-wide" data-layout="full">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField"><button id="input_2" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit" data-component="button" data-content="">SUBMIT</button></div>
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</li>
<li class="form-line always-hidden" data-type="control_text" id="id_6">
<div id="cid_6" class="form-input-wide always-hidden" data-layout="full">
<div id="text_6" class="form-html" data-component="text" tabindex="-1">
<p><span style="font-size: 10pt;">By submitting this form, you agree to be contacted by phone, email or text and that any associated call may be recorded for quality and training purposes. This form and any subsequent emails or text messages should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form</span>.</p>
</div>
</div>
</li>
<li class="form-line always-hidden" data-type="control_widget" id="id_29">
<div id="cid_29" class="form-input always-hidden" data-layout="full">
<div style="width:100%;text-align:Left" data-component="widget-directEmbed">
<div class="direct-embed-widgets get-form-page-url-widget " data-type="direct-embed" style="width:1px;min-height:50px"><input type='hidden' id='input_29' name='q29_typeA' class='form-hidden getParentURL'>
<script type='text/javascript' src='//widgets.jotform.io/getParentUrl/min/scripts.min.js'></script>
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</li>
<li style="display:none">Should be Empty: <input type="text" name="website" value="" type="hidden" /></li>
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EN 
ES