var headContent = "\n \n \n \n <\/title>\n <link href=\"https:\/\/orlandohealth.tfaforms.net\/dist\/form-builder\/5.0.0\/wforms-layout.css?v=1759036128\" rel=\"stylesheet\" type=\"text\/css\">\n <link href=\"https:\/\/orlandohealth.tfaforms.net\/dist\/form-builder\/5.0.0\/wforms-jsonly.css?v=1759036128\" rel=\"stylesheet\" type=\"text\/css\">\n <link href=\"https:\/\/orlandohealth.tfaforms.net\/uploads\/themes\/theme-26.css?v=1759036128\" rel=\"stylesheet\" type=\"text\/css\">\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/js\/FA__DOMContentLoadedEventDispatcher.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/wForms\/3.11\/js\/wforms.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/wForms\/3.11\/js\/localization-en_US.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/wForms\/3.11\/js\/wforms_prefill.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/dist\/jquery\/jquery.0416573c648d279fd758.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/js\/typeahead\/v1.2.0\/typeahead.bundle.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/dist\/analytics\/data-collector.e86d94bd97a6d88cf5db.js?v=1759036128\" type=\"text\/javascript\"><\/script>\n <script src=\"https:\/\/orlandohealth.tfaforms.net\/api_v2\/sst\/quick-publish?v=1759036128\" type=\"text\/javascript\"><\/script>\n \n <\/head>";
var bodyContent = "<!-- FORM: BODY SECTION --><body class=\"default wFormWebPage\">\n\n \n\n<div id=\"tfaContent\">\n\n <div class=\"wFormContainer\">\n <div class=\"wFormHeader\"><\/div>\n\n \n <style type=\"text\/css\">\n #tfa_41-L,\n label[id^=\"tfa_41[\"] {\n width: 500px !important;\n min-width: 0px;\n }\n \n #tfa_38,\n *[id^=\"tfa_38[\"] {\n width: 400px !important;\n }\n #tfa_38-D,\n *[id^=\"tfa_38[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_36-L,\n label[id^=\"tfa_36[\"] {\n width: 400px !important;\n min-width: 0px;\n }\n \n #tfa_35,\n *[id^=\"tfa_35[\"] {\n width: 400px !important;\n }\n #tfa_35-D,\n *[id^=\"tfa_35[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_454,\n *[id^=\"tfa_454[\"] {\n width: 400px !important;\n }\n #tfa_454-D,\n *[id^=\"tfa_454[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_28,\n *[id^=\"tfa_28[\"] {\n width: 400px !important;\n }\n #tfa_28-D,\n *[id^=\"tfa_28[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_26-L,\n label[id^=\"tfa_26[\"] {\n width: 255px !important;\n min-width: 0px;\n }\n \n #tfa_19,\n *[id^=\"tfa_19[\"] {\n width: 400px !important;\n }\n #tfa_19-D,\n *[id^=\"tfa_19[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_17,\n *[id^=\"tfa_17[\"] {\n width: 400px !important;\n }\n #tfa_17-D,\n *[id^=\"tfa_17[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_14,\n *[id^=\"tfa_14[\"] {\n width: 400px !important;\n }\n #tfa_14-D,\n *[id^=\"tfa_14[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_9,\n *[id^=\"tfa_9[\"] {\n width: 400px !important;\n }\n #tfa_9-D,\n *[id^=\"tfa_9[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_8,\n *[id^=\"tfa_8[\"] {\n width: 400px !important;\n }\n #tfa_8-D,\n *[id^=\"tfa_8[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_447,\n *[id^=\"tfa_447[\"] {\n width: 400px !important;\n }\n #tfa_447-D,\n *[id^=\"tfa_447[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_6,\n *[id^=\"tfa_6[\"] {\n width: 400px !important;\n }\n #tfa_6-D,\n *[id^=\"tfa_6[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_3,\n *[id^=\"tfa_3[\"] {\n width: !important;\n }\n #tfa_3-D,\n *[id^=\"tfa_3[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_2,\n *[id^=\"tfa_2[\"] {\n width: !important;\n }\n #tfa_2-D,\n *[id^=\"tfa_2[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n \n #tfa_1,\n *[id^=\"tfa_1[\"] {\n width: !important;\n }\n #tfa_1-D,\n *[id^=\"tfa_1[\"][class~=\"field-container-D\"] {\n width: auto !important;\n }\n <\/style><div class=\"\"><div class=\"wForm\" id=\"111-WRPR\" data-language=\"en_US\" dir=\"ltr\">\n<div class=\"codesection\" id=\"code-111\"><script src=\"https:\/\/www.orlandohealth.com\/-\/media\/formassembly\/formassembly_url_fields.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/www.orlandohealth.com\/-\/media\/formassembly\/formassembly_utm_fields.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/www.orlandohealth.com\/-\/media\/formassembly\/formassembly_reCAPTCHA.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/www.orlandohealth.com\/-\/media\/formassembly\/formassembly_phone_validation.js\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/www.orlandohealth.com\/-\/media\/formassembly\/formassembly_physician_finder.js\" type=\"text\/javascript\"><\/script>\n<\/div>\n<form method=\"post\" action=\"https:\/\/orlandohealth.tfaforms.net\/api_v2\/workflow\/processor\" class=\" labelsLeftAligned\" id=\"111\">\n<div class=\"htmlSection\" id=\"tfa_433\"><div class=\"htmlContent\" id=\"tfa_433-HTML\"><span class=\"reqMark\"><\/span> Indicates a required field<\/div><\/div>\n<div id=\"tfa_442\" class=\"section column group\"><table class=\"columnLayout\">\n<tr>\n<td><div class=\"oneField field-container-D \" id=\"tfa_429-D\">\n<label id=\"tfa_429-L\" class=\"label preField reqMark\" for=\"tfa_429\">First Name<\/label><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_429\" name=\"tfa_429\" value=\"\" title=\"First Name\" class='validate-custom \/^[^*|\\\":<>[\\]{}\\\\().;@&$0-9]+$\/ required'><\/div>\n<script type=\"text\/javascript\">\n if(typeof wFORMS != 'undefined') {\n if(wFORMS.behaviors.validation) {\n wFORMS.behaviors.validation.rules['customtfa_429'] = { selector: '*[id=\"tfa_429\"]', check: 'validateCustom'};\n wFORMS.behaviors.validation.messages['customtfa_429'] = \"Please enter a valid first name only.\";\n }\n }<\/script>\n<\/div><\/td>\n<td><div class=\"oneField field-container-D \" id=\"tfa_428-D\">\n<label id=\"tfa_428-L\" class=\"label preField reqMark\" for=\"tfa_428\">Last Name<\/label><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_428\" name=\"tfa_428\" value=\"\" title=\"Last Name\" class='validate-custom \/^[^*|\\\":<>[\\]{}\\\\().;@&$0-9]+$\/ required'><\/div>\n<script type=\"text\/javascript\">\n if(typeof wFORMS != 'undefined') {\n if(wFORMS.behaviors.validation) {\n wFORMS.behaviors.validation.rules['customtfa_428'] = { selector: '*[id=\"tfa_428\"]', check: 'validateCustom'};\n wFORMS.behaviors.validation.messages['customtfa_428'] = \"Please enter a valid last name only.\";\n }\n }<\/script>\n<\/div><\/td>\n<\/tr>\n<tr>\n<td><div class=\"oneField field-container-D hintsBelow \" id=\"tfa_425-D\">\n<label id=\"tfa_425-L\" class=\"label preField reqMark\" for=\"tfa_425\">Date of Birth<\/label><div class=\"inputWrapper\">\n<input aria-required=\"true\" type=\"text\" id=\"tfa_425\" name=\"tfa_425\" value=\"\" aria-describedby=\"tfa_425-HH\" min=\"1900-01-31\" max=\"-|0_Days{}\" title=\"Date of Birth\" class=\"validate-custom \/(0\\d{1}|1[0-2])\\\/([0-2]\\d{1}|3[0-1])\\\/(19|20)\\d{2}\/g required\"><span class=\"field-hint-inactive\" id=\"tfa_425-H\"><span id=\"tfa_425-HH\" class=\"hint\">MM\/DD\/YYYY<\/span><\/span>\n<\/div>\n<script type=\"text\/javascript\">\n if(typeof wFORMS != 'undefined') {\n if(wFORMS.behaviors.validation) {\n wFORMS.behaviors.validation.rules['customtfa_425'] = { selector: '*[id=\"tfa_425\"]', check: 'validateCustom'};\n wFORMS.behaviors.validation.messages['customtfa_425'] = \"Enter Valid Date\";\n }\n }<\/script>\n<\/div><\/td>\n<td><div class=\"oneField field-container-D \" id=\"tfa_427-D\">\n<label id=\"tfa_427-L\" class=\"label preField reqMark\" for=\"tfa_427\">Email<\/label><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_427\" name=\"tfa_427\" value=\"\" title=\"Email\" class=\"validate-email required\"><\/div>\n<\/div><\/td>\n<\/tr>\n<tr>\n<td><div class=\"oneField field-container-D \" id=\"tfa_444-D\">\n<label id=\"tfa_444-L\" class=\"label preField reqMark\" for=\"tfa_444\">Country<\/label><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_444\" name=\"tfa_444\" title=\"Country\" class=\"calc-varCountry required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_445\" id=\"tfa_445\" class=\"calcval-0\">United States, Canada, Puerto Rico<\/option>\n<option value=\"tfa_446\" id=\"tfa_446\" data-conditionals=\"#tfa_448\" class=\"calcval-1\">Other Country<\/option><\/select><\/div>\n<\/div><\/td>\n<td><div id=\"tfa_452\" class=\"section inline group\">\n<div class=\"oneField field-container-D hintsBelow \" id=\"tfa_426-D\">\n<label id=\"tfa_426-L\" class=\"label preField reqMark\" for=\"tfa_426\">Phone<\/label><div class=\"inputWrapper\">\n<input aria-required=\"true\" type=\"text\" id=\"tfa_426\" name=\"tfa_426\" value=\"\" autocomplete=\"tel\" aria-describedby=\"tfa_426-HH\" data-condition=\"`#tfa_447,notEquals,1`\" title=\"Phone\" class=\"required\"><span class=\"field-hint-inactive\" id=\"tfa_426-H\"><span id=\"tfa_426-HH\" class=\"hint\">(###) ###-####<\/span><\/span>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_448-D\">\n<label id=\"tfa_448-L\" class=\"label preField \" for=\"tfa_448\">International Phone<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_448\" name=\"tfa_448\" value=\"\" data-condition=\"`#tfa_446`\" title=\"International Phone\" class=\"\"><\/div>\n<\/div>\n<\/div><\/td>\n<\/tr>\n<tr><td><div class=\"oneField field-container-D \" id=\"tfa_424-D\">\n<label id=\"tfa_424-L\" class=\"label preField reqMark\" for=\"tfa_424\">ZIP Code<\/label><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_424\" name=\"tfa_424\" value=\"\" data-condition=\"`#tfa_447,notEquals,1`\" title=\"ZIP Code\" class=\"required\"><\/div>\n<\/div><\/td><\/tr>\n<\/table><\/div>\n<div class=\"oneField field-container-D wf-acl-hidden\" id=\"tfa_45-D\">\n<label id=\"tfa_45-L\" class=\"label preField \" for=\"tfa_45\">Physician<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_45\" name=\"tfa_45\" value=\"\" title=\"Physician\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_43-D\">\n<label id=\"tfa_43-L\" class=\"label preField \" for=\"tfa_43\">Reason for Appointment<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_43\" name=\"tfa_43\" value=\"\" title=\"Reason for Appointment\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D labelsAbove \" id=\"tfa_41-D\" role=\"group\" aria-labelledby=\"tfa_41-L\" data-tfa-labelledby=\"-L tfa_41-L\">\n<label id=\"tfa_41-L\" class=\"label preField \" data-tfa-check-label-for=\"tfa_41\">Let's Keep in Touch<\/label><br><div class=\"inputWrapper\"><span id=\"tfa_41\" class=\"choices horizontal \"><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_434\" class=\"\" id=\"tfa_434\" name=\"tfa_434\" aria-labelledby=\"tfa_434-L\" data-tfa-labelledby=\"tfa_41-L tfa_434-L\" data-tfa-parent-id=\"tfa_41\"><label class=\"label postField\" id=\"tfa_434-L\" for=\"tfa_434\"><span class=\"input-checkbox-faux\"><\/span><span style=\"color: rgb(81, 94, 89); font-family: Montserrat, sans-serif; font-size: 14.4px;\">Yes, I want Orlando Health to send me information about its various services via phone, email or direct mail.<\/span><\/label><\/span><\/span><\/div>\n<\/div>\n<fieldset id=\"tfa_430\" class=\"section wf-acl-hidden\">\n<legend id=\"tfa_430-L\">Hidden Fields<\/legend>\n<div class=\"oneField field-container-D \" id=\"tfa_38-D\">\n<label id=\"tfa_38-L\" class=\"label preField \" for=\"tfa_38\">Match Object<\/label><div class=\"inputWrapper\">\n<select id=\"tfa_38\" name=\"tfa_38\" disabled data-wforms-nooverwrite=\"disabled\" title=\"Match Object\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_39\" id=\"tfa_39\" class=\"\" selected data-default-value=\"true\">Patient<\/option>\n<option value=\"tfa_40\" id=\"tfa_40\" class=\"\">Provider<\/option><\/select><input type=\"hidden\" id=\"tfa_38-R\" name=\"tfa_38\" value=\"tfa_39\">\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D labelsRemoved \" id=\"tfa_36-D\" role=\"group\" aria-labelledby=\"tfa_36-L\" data-tfa-labelledby=\"-L tfa_36-L\"><div class=\"inputWrapper\"><span id=\"tfa_36\" class=\"choices vertical \"><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_37\" class=\"\" checked data-default-value=\"true\" id=\"tfa_37\" name=\"tfa_37\" aria-labelledby=\"tfa_37-L\" data-tfa-labelledby=\"tfa_36-L tfa_37-L\" data-tfa-parent-id=\"tfa_36\" disabled data-wforms-nooverwrite=\"disabled\"><input type=\"hidden\" id=\"tfa_36-R\" name=\"tfa_37\" value=\"tfa_37\"><label class=\"label postField\" id=\"tfa_37-L\" for=\"tfa_37\"><span class=\"input-checkbox-faux\"><\/span>FormAssembly Submission<\/label><\/span><\/span><\/div><\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_35-D\">\n<label id=\"tfa_35-L\" class=\"label preField \" for=\"tfa_35\">Form ID<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_35\" name=\"tfa_35\" value=\"111\" default=\"111\" readonly data-wforms-nooverwrite=\"disabled\" title=\"Form ID\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_454-D\">\n<label id=\"tfa_454-L\" class=\"label preField \" for=\"tfa_454\">Form Name<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_454\" name=\"tfa_454\" value=\"OH - Physician Finder - AR\" default=\"OH - Physician Finder - AR\" readonly data-wforms-nooverwrite=\"disabled\" title=\"Form Name\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_28-D\">\n<label id=\"tfa_28-L\" class=\"label preField \" for=\"tfa_28\">Form Type<\/label><div class=\"inputWrapper\">\n<select id=\"tfa_28\" name=\"tfa_28\" disabled data-wforms-nooverwrite=\"disabled\" title=\"Form Type\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_29\" id=\"tfa_29\" class=\"\" selected data-default-value=\"true\">Appointment Request<\/option>\n<option value=\"tfa_30\" id=\"tfa_30\" class=\"\">Download Guide<\/option>\n<option value=\"tfa_31\" id=\"tfa_31\" class=\"\">General Inquiry<\/option>\n<option value=\"tfa_32\" id=\"tfa_32\" class=\"\">Newsletter Opt In<\/option>\n<option value=\"tfa_33\" id=\"tfa_33\" class=\"\">Import<\/option>\n<option value=\"tfa_34\" id=\"tfa_34\" class=\"\">Event Signup<\/option><\/select><input type=\"hidden\" id=\"tfa_28-R\" name=\"tfa_28\" value=\"tfa_29\">\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D labelsRemoved hintsBelow \" id=\"tfa_26-D\" role=\"group\" aria-labelledby=\"tfa_26-L\" data-tfa-labelledby=\"-L tfa_26-L\"><div class=\"inputWrapper\">\n<span id=\"tfa_26\" class=\"choices vertical \"><span class=\"oneChoice\"><input type=\"checkbox\" value=\"tfa_27\" class=\"\" checked data-default-value=\"true\" id=\"tfa_27\" name=\"tfa_27\" aria-labelledby=\"tfa_27-L\" data-tfa-labelledby=\"tfa_26-L tfa_27-L\" data-tfa-parent-id=\"tfa_26\" aria-describedby=\"tfa_26-HH\" disabled data-wforms-nooverwrite=\"disabled\"><input type=\"hidden\" id=\"tfa_26-R\" name=\"tfa_27\" value=\"tfa_27\"><label class=\"label postField\" id=\"tfa_27-L\" for=\"tfa_27\"><span class=\"input-checkbox-faux\"><\/span>Send to AHC<\/label><\/span><\/span><span class=\"field-hint-inactive\" id=\"tfa_26-H\"><span id=\"tfa_26-HH\" class=\"hint\">Sends to the request to the Marketing call center. <\/span><\/span>\n<\/div><\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_19-D\">\n<label id=\"tfa_19-L\" class=\"label preField \" for=\"tfa_19\">Status<\/label><div class=\"inputWrapper\">\n<select id=\"tfa_19\" name=\"tfa_19\" disabled data-wforms-nooverwrite=\"disabled\" title=\"Status\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_20\" id=\"tfa_20\" class=\"\">New<\/option>\n<option value=\"tfa_21\" id=\"tfa_21\" class=\"\">Open<\/option>\n<option value=\"tfa_22\" id=\"tfa_22\" class=\"\">In Progress<\/option>\n<option value=\"tfa_23\" id=\"tfa_23\" class=\"\">On Hold<\/option>\n<option value=\"tfa_24\" id=\"tfa_24\" class=\"\">Escalated<\/option>\n<option value=\"tfa_25\" id=\"tfa_25\" class=\"\" selected data-default-value=\"true\">Closed<\/option><\/select><input type=\"hidden\" id=\"tfa_19-R\" name=\"tfa_19\" value=\"tfa_25\">\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_17-D\">\n<label id=\"tfa_17-L\" class=\"label preField \" for=\"tfa_17\">Campaign Id<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_17\" name=\"tfa_17\" value=\"7015e000000DZd6AAG\" default=\"7015e000000DZd6AAG\" readonly data-wforms-nooverwrite=\"disabled\" title=\"Campaign Id\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_14-D\">\n<label id=\"tfa_14-L\" class=\"label preField \" for=\"tfa_14\">Subscriptions<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_14\" name=\"tfa_14\" value=\"\" title=\"Subscriptions\" class=\"\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_9-D\">\n<label id=\"tfa_9-L\" class=\"label preField \" for=\"tfa_9\">Case Origin<\/label><div class=\"inputWrapper\">\n<select id=\"tfa_9\" name=\"tfa_9\" disabled data-wforms-nooverwrite=\"disabled\" title=\"Case Origin\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_10\" id=\"tfa_10\" class=\"\">Email<\/option>\n<option value=\"tfa_11\" id=\"tfa_11\" class=\"\">Phone<\/option>\n<option value=\"tfa_12\" id=\"tfa_12\" class=\"\" selected data-default-value=\"true\">Web<\/option>\n<option value=\"tfa_13\" id=\"tfa_13\" class=\"\">Internal<\/option><\/select><input type=\"hidden\" id=\"tfa_9-R\" name=\"tfa_9\" value=\"tfa_12\">\n<\/div>\n<\/div>\n<input type=\"hidden\" id=\"tfa_8\" name=\"tfa_8\" value=\"0125e000000DZqqAAG\" class=\"\"><div class=\"oneField field-container-D \" id=\"tfa_447-D\">\n<label id=\"tfa_447-L\" class=\"label preField \" for=\"tfa_447\">International Request<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_447\" name=\"tfa_447\" value=\"\" readonly data-conditionals=\"#tfa_426,#tfa_424\" title=\"International Request\" class=\"formula=varCountry readonly\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D \" id=\"tfa_6-D\">\n<label id=\"tfa_6-L\" class=\"label preField \" for=\"tfa_6\">Submitted From URL<\/label><div class=\"inputWrapper\"><textarea id=\"tfa_6\" name=\"tfa_6\" title=\"Submitted From URL\" class=\"\"><\/textarea><\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"tfa_431\" class=\"section column wf-acl-hidden\">\n<legend id=\"tfa_431-L\">UTM<\/legend>\n<table class=\"columnLayout\">\n<tr>\n<td><div class=\"oneField field-container-D \" id=\"tfa_5-D\">\n<label id=\"tfa_5-L\" class=\"label preField \" for=\"tfa_5\">UTM Campaign<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_5\" name=\"tfa_5\" value=\"\" title=\"UTM Campaign\" class=\"\"><\/div>\n<\/div><\/td>\n<td><div class=\"oneField field-container-D \" id=\"tfa_4-D\">\n<label id=\"tfa_4-L\" class=\"label preField \" for=\"tfa_4\">UTM Content<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_4\" name=\"tfa_4\" value=\"\" title=\"UTM Content\" class=\"\"><\/div>\n<\/div><\/td>\n<\/tr>\n<tr>\n<td><div class=\"oneField field-container-D \" id=\"tfa_3-D\">\n<label id=\"tfa_3-L\" class=\"label preField \" for=\"tfa_3\">UTM Medium<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_3\" name=\"tfa_3\" value=\"\" title=\"UTM Medium\" class=\"\"><\/div>\n<\/div><\/td>\n<td><div class=\"oneField field-container-D \" id=\"tfa_2-D\">\n<label id=\"tfa_2-L\" class=\"label preField \" for=\"tfa_2\">UTM Source<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_2\" name=\"tfa_2\" value=\"\" title=\"UTM Source\" class=\"\"><\/div>\n<\/div><\/td>\n<\/tr>\n<tr>\n<td><div class=\"oneField field-container-D \" id=\"tfa_1-D\">\n<label id=\"tfa_1-L\" class=\"label preField \" for=\"tfa_1\">UTM Term<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_1\" name=\"tfa_1\" value=\"\" title=\"UTM Term\" class=\"\"><\/div>\n<\/div><\/td>\n<td><div class=\"oneField field-container-D \" id=\"tfa_440-D\">\n<label id=\"tfa_440-L\" class=\"label preField \" for=\"tfa_440\">GA Client Id<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_440\" name=\"tfa_440\" value=\"\" title=\"GA Client Id\" class=\"\"><\/div>\n<\/div><\/td>\n<\/tr>\n<tr>\n<td><div class=\"oneField field-container-D \" id=\"tfa_441-D\">\n<label id=\"tfa_441-L\" class=\"label preField \" for=\"tfa_441\">GA Session Id<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_441\" name=\"tfa_441\" value=\"\" title=\"GA Session Id\" class=\"\"><\/div>\n<\/div><\/td>\n<td><div class=\"oneField field-container-D \" id=\"tfa_453-D\">\n<label id=\"tfa_453-L\" class=\"label preField \" for=\"tfa_453\">GA GCLID<\/label><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_453\" name=\"tfa_453\" value=\"\" title=\"GA GCLID\" class=\"\"><\/div>\n<\/div><\/td>\n<\/tr>\n<\/table>\n<\/fieldset>\n<div class=\"actions\" id=\"111-A\" data-contentid=\"submit_button\">\n<div id=\"google-captcha\" style=\"display: none\">\n<br><div class=\"captcha\">\n<div class=\"oneField\">\n<div class=\"g-recaptcha\" id=\"g-recaptcha-render-div\"><\/div>\n<div class=\"g-captcha-error\"><\/div>\n<br>\n<\/div>\n<div class=\"captchaHelp\">reCAPTCHA helps prevent automated form spam.<br>\n<\/div>\n<div id=\"disabled-explanation\" class=\"captchaHelp\" style=\"display: none\">The submit button will be disabled until you complete the CAPTCHA.<\/div>\n<\/div>\n<\/div>\n<input type=\"submit\" data-label=\"Submit\" class=\"primaryAction\" id=\"submit_button\" value=\"Submit\">\n<\/div>\n<div style=\"clear:both\"><\/div>\n<input type=\"hidden\" value=\"977-3e786b948cf02a1dfa8cc8bb2ffb1df3\" name=\"tfa_dbCounters\" id=\"tfa_dbCounters\" autocomplete=\"off\"><input type=\"hidden\" value=\"111\" name=\"tfa_dbFormId\" id=\"tfa_dbFormId\"><input type=\"hidden\" value=\"\" name=\"tfa_dbResponseId\" id=\"tfa_dbResponseId\"><input type=\"hidden\" value=\"116283748b3e868b2b041ae13ac0264d\" name=\"tfa_dbControl\" id=\"tfa_dbControl\"><input type=\"hidden\" value=\"\" name=\"tfa_dbWorkflowSessionUuid\" id=\"tfa_dbWorkflowSessionUuid\"><input type=\"hidden\" value=\"0\" name=\"tfa_dbDataflowId\" id=\"tfa_dbDataflowId\"><input type=\"hidden\" value=\"1759036128\" name=\"tfa_dbTimeStarted\" id=\"tfa_dbTimeStarted\" autocomplete=\"off\"><input type=\"hidden\" value=\"10\" name=\"tfa_dbVersionId\" id=\"tfa_dbVersionId\"><input type=\"hidden\" value=\"false\" name=\"startWorkflow\" id=\"startWorkflow\"><input type=\"hidden\" value=\"\" name=\"tfa_switchedoff\" id=\"tfa_switchedoff\">\n<\/form>\n<\/div><\/div><div class=\"wFormFooter\"><p class=\"supportInfo\"><br><\/p><\/div>\n\n<\/div>\n\n\n <script id=\"analytics-collector-script\" type=\"text\/javascript\" src=\"https:\/\/orlandohealth.tfaforms.net\/dist\/analytics\/data-collector.e86d94bd97a6d88cf5db.js\" data-customer-id=\"24380\" data-endpoint=\"https:\/\/analytics.formassembly.com\/v1\/traces\"><\/script>\n\n \n<script type=\"text\/javascript\" data-for=\"FA__DOMContentLoadedEventDispatch\" src=\"https:\/\/orlandohealth.tfaforms.net\/js\/FA__DOMContentLoadedEventDispatcher.js\" defer><\/script>\n\n <style>\n .captcha {\n padding-bottom: 1em !important;\n }\n .wForm .captcha .oneField {\n margin: 0;\n padding: 0;\n }\n<\/style>\n<script type=\"text\/javascript\">\n \/\/ initialize our variables\n var captchaReady = 0;\n var wFORMSReady = 0;\n var isConditionalSubmitEnabled = false;\n \/\/ when wForms is loaded call this\n var wformsReadyCallback = function () {\n \/\/ using this var to denote if wForms is loaded\n wFORMSReady = 1;\n isConditionalSubmitEnabled = document.getElementById('submit_button').hasAttribute('data-condition');\n \/\/ call our recaptcha function which is dependent on both\n \/\/ wForms and an async call to google\n \/\/ note the meat of this function wont fire until both\n \/\/ wFORMSReady = 1 and captchaReady = 1\n onloadCallback();\n }\n var gCaptchaReadyCallback = function() {\n \/\/ using this var to denote if captcha is loaded\n captchaReady = 1;\n isConditionalSubmitEnabled = document.getElementById('submit_button').hasAttribute('data-condition');\n \/\/ call our recaptcha function which is dependent on both\n \/\/ wForms and an async call to google\n \/\/ note the meat of this function wont fire until both\n \/\/ wFORMSReady = 1 and captchaReady = 1\n onloadCallback();\n };\n \/\/ add event listener to fire when wForms is fully loaded\n document.addEventListener(\"wFORMSLoaded\", wformsReadyCallback);\n var enableSubmitButton = function() {\n var submitButton = document.getElementById('submit_button');\n var explanation = document.getElementById('disabled-explanation');\n var isConditionalSubmitConditionMet = wFORMS.behaviors.condition.isConditionalSubmitConditionMet;\n if (\n submitButton != null &&\n (isConditionalSubmitEnabled && isConditionalSubmitConditionMet) ||\n !isConditionalSubmitEnabled\n )\n {\n submitButton.removeAttribute('disabled');\n if (explanation != null) {\n explanation.style.display = 'none';\n }\n }\n };\n var disableSubmitButton = function() {\n var submitButton = document.getElementById('submit_button');\n var explanation = document.getElementById('disabled-explanation');\n if (submitButton != null) {\n submitButton.disabled = true;\n if (explanation != null) {\n explanation.style.display = 'block';\n }\n }\n };\n \/\/ call this on both captcha async complete and wforms fully\n \/\/ initialized since we can't be sure which will complete first\n \/\/ and we need both done for this to function just check that they are\n \/\/ done to fire the functionality\n var onloadCallback = function () {\n \/\/ if our captcha is ready (async call completed)\n \/\/ and wFORMS is completely loaded then we are ready to add\n \/\/ the captcha to the page\n if (captchaReady && wFORMSReady) {\n grecaptcha.enterprise.render('g-recaptcha-render-div', {\n 'sitekey': '6LfMg_EaAAAAAMhDNLMlgqDChzmtYHlx1yU2y7GI',\n 'theme': 'light',\n 'size': 'normal',\n 'callback': 'enableSubmitButton',\n 'expired-callback': 'disableSubmitButton'\n })\n if (!wFORMS.instances['paging']) {\n document.getElementById(\"g-recaptcha-render-div\").parentNode.parentNode.parentNode.style.display = \"block\";\n }\n document.getElementById(\"g-recaptcha-render-div\").getAttributeNode('id').value = 'tfa_captcha_text';\n var captchaError = '';\n if (captchaError == '1') {\n var errMsgText = 'The CAPTCHA was not completed successfully.';\n var errMsgDiv = document.createElement('div');\n errMsgDiv.id = \"tfa_captcha_text-E\";\n errMsgDiv.className = \"err errMsg\";\n errMsgDiv.innerText = errMsgText;\n var loc = document.querySelector('.g-captcha-error');\n loc.insertBefore(errMsgDiv, loc.childNodes[0]);\n \/* See wFORMS.behaviors.paging.applyTo for origin of this code *\/\n if (wFORMS.instances['paging']) {\n var b = wFORMS.instances['paging'][0];\n var pp = base2.DOM.Element.querySelector(document, wFORMS.behaviors.paging.CAPTCHA_ERROR);\n if (pp) {\n var lastPage = 1;\n for (var i = 1; i < 100; i++) {\n if (b.behavior.isLastPageIndex(i)) {\n lastPage = i;\n break;\n }\n }\n b.jumpTo(lastPage);\n }\n }\n }\n }\n }\n<\/script>\n<script src=\"https:\/\/www.google.com\/recaptcha\/enterprise.js?onload=gCaptchaReadyCallback&render=explicit&hl=en_US\" async defer><\/script>\n<script type=\"text\/javascript\">\n document.addEventListener(\"DOMContentLoaded\", function() {\n var warning = document.getElementById(\"javascript-warning\");\n if (warning != null) {\n warning.parentNode.removeChild(warning);\n }\n var explanation = document.getElementById('disabled-explanation');\n var submitButton = document.getElementById('submit_button');\n if (submitButton != null) {\n submitButton.disabled = true;\n if (explanation != null) {\n explanation.style.display = 'block';\n }\n }\n });\n<\/script>\n\n<script type=\"text\/javascript\">\n document.addEventListener(\"FA__DOMContentLoaded\", function(){\n const FORM_TIME_START = Math.floor((new Date).getTime()\/1000);\n let formElement = document.getElementById(\"tfa_0\");\n if (null === formElement) {\n formElement = document.getElementById(\"0\");\n }\n let appendJsTimerElement = function(){\n let formTimeDiff = Math.floor((new Date).getTime()\/1000) - FORM_TIME_START;\n let cumulatedTimeElement = document.getElementById(\"tfa_dbCumulatedTime\");\n if (null !== cumulatedTimeElement) {\n let cumulatedTime = parseInt(cumulatedTimeElement.value);\n if (null !== cumulatedTime && cumulatedTime > 0) {\n formTimeDiff += cumulatedTime;\n }\n }\n let jsTimeInput = document.createElement(\"input\");\n jsTimeInput.setAttribute(\"type\", \"hidden\");\n jsTimeInput.setAttribute(\"value\", formTimeDiff.toString());\n jsTimeInput.setAttribute(\"name\", \"tfa_dbElapsedJsTime\");\n jsTimeInput.setAttribute(\"id\", \"tfa_dbElapsedJsTime\");\n jsTimeInput.setAttribute(\"autocomplete\", \"off\");\n if (null !== formElement) {\n formElement.appendChild(jsTimeInput);\n }\n };\n if (null !== formElement) {\n if(formElement.addEventListener){\n formElement.addEventListener('submit', appendJsTimerElement, false);\n } else if(formElement.attachEvent){\n formElement.attachEvent('onsubmit', appendJsTimerElement);\n }\n }\n });\n<\/script>\n\n<script type=\"text\/javascript\">\n if(wFORMS.behaviors.prefill) wFORMS.behaviors.prefill.skip = true;\n<\/script>\n\n\n\n <\/div>\n\n\n \n\n\n<\/body>";
var resumeUrl = null;
var baseUrl = "https:\/\/orlandohealth.tfaforms.net";
/**
* Main entry point, called when the DOM is loaded.
*/
function loadFormAssemblyFormHeadAndBodyContents() {
var targetElement = getTargetElement();
var formBodyWrapper = createFormBodyWrapper();
injectHeadContent();
injectBodyContent(formBodyWrapper, targetElement);
addResumeLink();
document.addEventListener('FA__DOMContentLoaded', function () {
executeBodyScripts(formBodyWrapper);
// Set up FA$ for autosuggest behavior (jQuery in noConflict mode)
if (typeof $ !== 'undefined' && $.noConflict) {
window.FA$ = $.noConflict(true);
}
// Apply prefill behavior to enable URL parameter prefilling
var forms = document.querySelectorAll('form');
forms.forEach(function(form) {
if (wFORMS && wFORMS.behaviors && wFORMS.behaviors.prefill) {
wFORMS.behaviors.prefill.skip = false;
wFORMS.behaviors.prefill.applyTo(form);
}
});
});
}
window.addEventListener('DOMContentLoaded', loadFormAssemblyFormHeadAndBodyContents);
/**
* Finds the target DOM element where the form should be injected.
* @returns {HTMLElement|null} The target element or null if not found.
*/
function getTargetElement() {
var quickPublishScript = document.querySelector('script[data-qp-target-id]');
if (quickPublishScript) {
var elementID = quickPublishScript.getAttribute('data-qp-target-id');
return document.getElementById(elementID);
}
return null;
}
/**
* Creates the main wrapper div for the form's body content.
* @returns {HTMLDivElement}
*/
function createFormBodyWrapper() {
var bodyWrapperDiv = document.createElement('div');
bodyWrapperDiv.id = "FA__QP__BODYWRAPPERDIV";
return bodyWrapperDiv;
}
/**
* Injects the form's header content (styles, scripts) into the main document.
*/
function injectHeadContent() {
var head = document.createElement('head');
head.innerHTML = headContent;
var headElements = Array.from(head.children);
var scriptElements = headElements.filter(function(el) { return el.nodeName === 'SCRIPT'; });
var otherElements = headElements.filter(function(el) { return el.nodeName !== 'SCRIPT'; });
otherElements.forEach(function(el) { document.head.appendChild(el); });
loadHeadScriptsSequentially(scriptElements);
}
/**
* Loads header script tags sequentially to maintain order.
* @param {HTMLScriptElement[]} scriptElements - An array of script elements to load.
*/
function loadHeadScriptsSequentially(scriptElements) {
var script = scriptElements.shift();
if (!script) {
document.dispatchEvent(new Event('FA__DOMContentLoaded'));
return;
}
var newScript = document.createElement('script');
Array.from(script.attributes).forEach(function(attr) { newScript.setAttribute(attr.name, attr.value); });
newScript.innerHTML = script.innerHTML;
if (script.src) {
newScript.onload = function() { loadHeadScriptsSequentially(scriptElements); };
document.head.appendChild(newScript);
} else {
document.head.appendChild(newScript);
loadHeadScriptsSequentially(scriptElements);
}
}
/**
* Injects the form's body content into the target element.
* @param {HTMLDivElement} formBodyWrapper - The div that will contain the form.
* @param {HTMLElement|null} targetElement - The element to inject the form into.
*/
function injectBodyContent(formBodyWrapper, targetElement) {
var body = document.createElement('body');
body.innerHTML = bodyContent;
Array.from(body.children).forEach(function(el) { formBodyWrapper.appendChild(el); });
if (targetElement) {
targetElement.appendChild(formBodyWrapper);
} else {
document.body.appendChild(formBodyWrapper);
}
}
/**
* If a resume URL is provided, it finds the "Save and Resume" containers
* and injects the resume link.
*/
function addResumeLink() {
if (!resumeUrl) return;
var oneFieldContainers = document.querySelectorAll('.wForm .saveAndResume > .oneField');
oneFieldContainers.forEach(function (container) {
var separator = document.createTextNode(' | ');
var resumeLink = document.createElement('a');
resumeLink.href = baseUrl + resumeUrl;
resumeLink.innerHTML = 'Resume a previously saved form';
resumeLink.addEventListener('click', function(event) {
if (!confirm('Are you sure you want to resume a previous response? Any information you just entered on this page will be discarded.')) {
event.preventDefault();
}
});
container.appendChild(separator);
container.appendChild(resumeLink);
});
}
/**
* Finds and re-executes script tags from the form's body.
* @param {HTMLDivElement} formBodyWrapper - The wrapper containing the form.
*/
function executeBodyScripts(formBodyWrapper) {
var scriptTags = formBodyWrapper.querySelectorAll('script');
scriptTags.forEach(function (scriptTag) {
// Skip jQuery, Typeahead, Kalendae, and Calendar scripts that are already loaded in the head
if (scriptTag.src && (
scriptTag.src.includes('jquery.js') ||
scriptTag.src.includes('typeahead.bundle.js') ||
scriptTag.src.includes('/js/kalendae/') ||
scriptTag.src.includes('wforms_calendar.js')
)) {
return;
}
// Skip noConflict scripts that are meant for jQuery/Typeahead
if (scriptTag.innerHTML && scriptTag.innerHTML.includes('noConflict')) {
return;
}
var script = document.createElement('script');
Array.from(scriptTag.attributes).forEach(function(attr) { script.setAttribute(attr.name, attr.value); });
script.innerHTML = scriptTag.innerHTML;
scriptTag.parentNode.replaceChild(script, scriptTag);
});
}