/*jslint nomen:false, debug:true, evil:true, vars:false, browser:true, forin:true, undef:false, white:false */
/**
* Includes a Form with javascript
* @param {Object} formId
* @param {Object} initialHeight
* @param {Object} iframeCode
*/
function FrameBuilder (formId, appendTo, initialHeight, iframeCode){
this.formId = formId;
this.initialHeight = initialHeight;
this.iframeCode = iframeCode;
this.frame = null;
this.timeInterval= 200;
this.appendTo = appendTo || false;
// initialize function for object
this.init = function(){
this.createFrame();
this.addFrameContent(this.iframeCode);
};
// Create the frame
this.createFrame = function(){
var htmlCode = "<"+"iframe src=\"\" allowtransparency=\"true\" frameborder=\"0\" name=\""+this.formId+"\" id=\""+this.formId+"\" style=\"width:100%; height:"+this.initialHeight+"px; border:none;\" scrolling=\"no\">";
if(this.appendTo === false){
document.write(htmlCode);
}else{
var tmp = document.createElement('div');
tmp.innerHTML = htmlCode;
var a = this.appendTo;
document.getElementById(a).appendChild(tmp.firstChild);
}
// also get the frame for future use.
this.frame = document.getElementById(this.formId);
// set the time on the on load event of the frame
this.addEvent(this.frame, 'load', this.bindMethod(this.setTimer, this));
};
// add event function for different browsers
this.addEvent = function( obj, type, fn ) {
if ( obj.attachEvent ) {
obj["e"+type+fn] = fn;
obj[type+fn] = function() { obj["e"+type+fn]( window.event ); };
obj.attachEvent( "on"+type, obj[type+fn] );
}
else{
obj.addEventListener( type, fn, false );
}
};
this.addFrameContent = function (string){
string = string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>', 'gim'), 'src="http://api.recaptcha.net/js/recaptcha_ajax.js"><'+'div id="recaptcha_div"><'+'/div>'+
'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+
'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+
'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+
' }<'+'/script>');
string = string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/, '$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');
var frameDocument = (this.frame.contentWindow) ? this.frame.contentWindow : (this.frame.contentDocument.document) ? this.frame.contentDocument.document : this.frame.contentDocument;
frameDocument.document.open();
frameDocument.document.write(string);
setTimeout( function(){
frameDocument.document.close();
try{
if('JotFormFrameLoaded' in window){
JotFormFrameLoaded();
}
}catch(e){}
},200);
};
this.setTimer = function(){
var self = this;
this.interval = setTimeout(function(){self.changeHeight();},this.timeInterval);
};
this.changeHeight = function (){
var actualHeight = this.getBodyHeight();
var currentHeight = this.getViewPortHeight();
if(actualHeight === undefined){
this.frame.style.height = "100%";
if(!this.frame.style.minHeight){
this.frame.style.minHeight = "300px";
}
}else if (Math.abs(actualHeight - currentHeight) > 18){
this.frame.style.height = (actualHeight)+"px";
}
this.setTimer();
};
this.bindMethod = function(method, scope) {
return function() {
method.apply(scope,arguments);
};
};
this.getBodyHeight = function (){
var height;
var scrollHeight;
var offsetHeight;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.document.height){
height = this.frame.contentWindow.document.height;
//Emre: to prevent "iframe height" problem (61059)
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
} else if (this.frame.contentWindow.document.body){
if (this.frame.contentWindow.document.body.scrollHeight){
height = scrollHeight = this.frame.contentWindow.document.body.scrollHeight;
}
if (this.frame.contentWindow.document.body.offsetHeight){
height = offsetHeight = this.frame.contentWindow.document.body.offsetHeight;
}
if (scrollHeight && offsetHeight){
height = Math.max(scrollHeight, offsetHeight);
}
}
}catch(e){ }
return height;
};
this.getViewPortHeight = function(){
var height = 0;
try{ // Prevent IE from throw errors
if (this.frame.contentWindow.window.innerHeight)
{
height = this.frame.contentWindow.window.innerHeight - 18;
}
else if ((this.frame.contentWindow.document.documentElement) &&
(this.frame.contentWindow.document.documentElement.clientHeight))
{
height = this.frame.contentWindow.document.documentElement.clientHeight;
}
else if ((this.frame.contentWindow.document.body) &&
(this.frame.contentWindow.document.body.clientHeight))
{
height = this.frame.contentWindow.document.body.clientHeight;
}
}catch(e){ }
return height;
};
this.init();
}
FrameBuilder.get = [];
var i1221251269 = new FrameBuilder("1221251269", false, "", "\n\n\n\n\nForm<\/title>\n<link href=\"http:\/\/max.jotfor.ms\/min\/g=formCss?3.0.2434\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"http:\/\/www.jotform.com\/css\/styles\/baby_blue.css\" \/>\n<style type=\"text\/css\">\n .form-label{\n width:140px !important;\n }\n .form-label-left{\n width:140px !important;\n }\n .form-line{\n padding:10px;\n }\n .form-label-right{\n width:140px !important;\n }\n body, html{\n margin:0;\n padding:0;\n background:rgb(215, 233, 243);\n }\n\n .form-all{\n margin:0px auto;\n padding-top:0px;\n width:750px;\n background:rgb(215, 233, 243);\n color:rgb(57, 79, 95) !important;\n font-family:Tahoma;\n font-size:12px;\n }\n<\/style>\n\n<script src=\"http:\/\/max.jotfor.ms\/min\/g=jotform?3.0.2434\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n JotForm.jsForm = true;\n\n JotForm.init(function(){\n $('input_3').hint('Business Name ');\n $('input_42').hint('Ordered by');\n JotForm.description('input_43', 'If you have ordered from Nmotion before, you may skip this field.');\n $('input_44').hint('yourname@youremail.com');\n $('input_48').spinner({ imgPath:'http:\/\/www.jotform.com\/images\/', width: '45', maxValue:'105', minValue:'5', allowNegative: false, addAmount: 10, value:'30' });\n JotForm.description('input_48', 'You may type in an exact age in the text field below or just choose an approximate age from the spinner dial.');\n $('input_49').spinner({ imgPath:'http:\/\/www.jotform.com\/images\/', width: '45', maxValue:'400', minValue:'40', allowNegative: false, addAmount: 50, value:'100' });\n JotForm.description('input_49', 'Type a value in the text field below if you wish to give exact weight. Otherwise, you may choose an approximate value from the spin selector. ');\n $('input_30').hint('Degrees\/mm\/inches');\n JotForm.description('input_30', 'You may enter a number for degrees followed by D (Ex: 5D). You can enter a fraction for inches (Ex: 1\/8) Or enter mm for milimeters (Ex 3mm)');\n $('input_33').hint('Degrees\/mm\/inches');\n JotForm.description('input_33', 'You may enter a number for degrees followed by D (Ex: 5D). You can enter a fraction for inches (Ex: 1\/8) Or enter mm for milimeters (Ex 3mm)');\n $('input_34').hint('Degrees\/mm\/inches');\n JotForm.description('input_34', 'You may enter a number for degrees followed by D (Ex: 5D). You can enter a fraction for inches (Ex: 1\/8) Or enter mm for milimeters (Ex 3mm)');\n $('input_35').hint('Degrees\/mm\/inches');\n JotForm.description('input_35', 'You may enter a number for degrees followed by D (Ex: 5D). You can enter a fraction for inches (Ex: 1\/8) Or enter mm for milimeters (Ex 3mm)');\n $('input_26').hint('L? R? B\/L? +inches');\n JotForm.description('input_26', 'For a heel lift, please enter l or R or B\/L and a fraction for inches or mm for millimeters.');\n JotForm.setCalendar(\"47\");\n $('input_51').hint('1 step Rx.-Name this order to save as profile.');\n JotForm.description('input_51', 'You can set up order profiles to save time. Just name this set of instructions. Then, for future orders of the same type, simply enter the profile name you chose in this blank. ie: \\\"Sport1\\\", \\\"Sport2\\\" \\\"Dress1\\\" etc. ');\n JotForm.description('input_41', 'Tip: Sending<br \/>unzipped files works;<br \/>but, takes longer.');\n });\n\n clearInterval(jsTime);\n }catch(e){}}, 1000);\n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"http:\/\/submit.jotform.com\/submit.php\" method=\"post\" enctype=\"multipart\/form-data\" name=\"form_1221251269\" id=\"1221251269\" accept-charset=\"utf-8\">\n <input type=\"hidden\" name=\"formID\" value=\"1221251269\" \/>\n <div class=\"form-all\">\n <ul class=\"form-section\">\n <li id=\"cid_1\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_1\" class=\"form-header\">\n NMOTION Orthotic Rx Form\n <\/h2>\n <div id=\"subHeader_1\" class=\"form-subHeader\">\n 3403 N. Broadway, Knoxville, TN 37917 (865) 765-5650\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_3\">\n <label class=\"form-label-top\" id=\"label_3\" for=\"input_3\">\n Account Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_3\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_3\" name=\"q3_accountName\" size=\"20\" maxlength=\"30\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_42\">\n <label class=\"form-label-top\" id=\"label_42\" for=\"input_42\"> Practitioner Name <\/label>\n <div id=\"cid_42\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_42\" name=\"q42_practitionerName\" size=\"20\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_43\">\n <label class=\"form-label-top\" id=\"label_43\" for=\"input_43\"> Address\/Phone-if new <\/label>\n <div id=\"cid_43\" class=\"form-input-wide\">\n <textarea id=\"input_43\" class=\"form-textarea\" name=\"q43_addressphoneifNew\" cols=\"35\" rows=\"2\"><\/textarea>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_44\">\n <label class=\"form-label-top\" id=\"label_44\" for=\"input_44\"> Account Email (opt) <\/label>\n <div id=\"cid_44\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_44\" name=\"q44_accountEmail\" size=\"40\" maxlength=\"40\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_4\">\n <label class=\"form-label-top\" id=\"label_4\" for=\"input_4\"> Contact me by <\/label>\n <div id=\"cid_4\" class=\"form-input-wide\">\n <div class=\"form-multiple-column\"><span class=\"form-checkbox-item\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_4_0\" name=\"q4_contactMe4[]\" value=\"Phone\" \/>\n <label for=\"input_4_0\"> Phone <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_4_1\" name=\"q4_contactMe4[]\" value=\"Email\" \/>\n <label for=\"input_4_1\"> Email <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_5\">\n <label class=\"form-label-top\" id=\"label_5\" for=\"input_5\">\n Patient Name<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_5\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox validate[required]\" id=\"input_5\" name=\"q5_patientName5\" size=\"25\" maxlength=\"25\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_8\">\n <label class=\"form-label-top\" id=\"label_8\" for=\"input_8\">\n Gender<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_8\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_8_0\" name=\"q8_gender8[]\" value=\"Male\" \/>\n <label for=\"input_8_0\"> Male <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_8_1\" name=\"q8_gender8[]\" value=\"Female\" \/>\n <label for=\"input_8_1\"> Female <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_48\">\n <label class=\"form-label-top\" id=\"label_48\" for=\"input_48\"> Approx. Age <\/label>\n <div id=\"cid_48\" class=\"form-input-wide\">\n <input type=\"number\" id=\"input_48\" name=\"q48_approxAge48\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_49\">\n <label class=\"form-label-top\" id=\"label_49\" for=\"input_49\"> Approx. Weight <\/label>\n <div id=\"cid_49\" class=\"form-input-wide\">\n <input type=\"number\" id=\"input_49\" name=\"q49_approxWeight49\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_9\">\n <label class=\"form-label-top\" id=\"label_9\" for=\"input_9\">\n Shoe Size<span class=\"form-required\">*<\/span>\n <\/label>\n <div id=\"cid_9\" class=\"form-input-wide\">\n <select class=\"form-dropdown validate[required]\" style=\"width:150px\" id=\"input_9\" name=\"q9_shoeSize9\">\n <option> <\/option>\n <option selected=\"selected\" value=\"Select\"> Select <\/option>\n <option value=\"3\"> 3 <\/option>\n <option value=\"4\"> 4 <\/option>\n <option value=\"5\"> 5 <\/option>\n <option value=\"5.5\"> 5.5 <\/option>\n <option value=\"6\"> 6 <\/option>\n <option value=\"6.5\"> 6.5 <\/option>\n <option value=\"7\"> 7 <\/option>\n <option value=\"7.5\"> 7.5 <\/option>\n <option value=\"8\"> 8 <\/option>\n <option value=\"8.5\"> 8.5 <\/option>\n <option value=\"9\"> 9 <\/option>\n <option value=\"9.5\"> 9.5 <\/option>\n <option value=\"10\"> 10 <\/option>\n <option value=\"10.5\"> 10.5 <\/option>\n <option value=\"11\"> 11 <\/option>\n <option value=\"11.5\"> 11.5 <\/option>\n <option value=\"12\"> 12 <\/option>\n <option value=\"12.5\"> 12.5 <\/option>\n <option value=\"13\"> 13 <\/option>\n <option value=\"14\"> 14 <\/option>\n <option value=\"15\"> 15 <\/option>\n <option value=\"16\"> 16 <\/option>\n <option value=\"17\"> 17 <\/option>\n <option value=\"18\"> 18 <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_10\">\n <label class=\"form-label-top\" id=\"label_10\" for=\"input_10\"> Shoe Type <\/label>\n <div id=\"cid_10\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:175px\" id=\"input_10\" name=\"q10_shoeType\">\n <option> <\/option>\n <option selected=\"selected\" value=\"Select\"> Select <\/option>\n <option value=\"Athletic\"> Athletic <\/option>\n <option value=\"Extra Depth\"> Extra Depth <\/option>\n <option value=\"Work Boot\"> Work Boot <\/option>\n <option value=\"Dress\"> Dress <\/option>\n <option value=\"Other(see notes)\"> Other(see notes) <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_12\">\n <label class=\"form-label-top\" id=\"label_12\" for=\"input_12\"> Principal Use <\/label>\n <div id=\"cid_12\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:175px\" id=\"input_12\" name=\"q12_principalUse12\">\n <option> <\/option>\n <option value=\"Work\"> Work <\/option>\n <option value=\"Exercise\"> Exercise <\/option>\n <option value=\"Casual\"> Casual <\/option>\n <option selected=\"selected\" value=\"Select\"> Select <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_11\">\n <label class=\"form-label-left\" id=\"label_11\" for=\"input_11\"> Diagnosis and Special Instructions <\/label>\n <div id=\"cid_11\" class=\"form-input\">\n <textarea id=\"input_11\" class=\"form-textarea\" name=\"q11_diagnosisAnd\" cols=\"63\" rows=\"3\"><\/textarea>\n <\/div>\n <\/li>\n <li id=\"cid_15\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_15\" class=\"form-header\">\n Orthotic Details\n <\/h2>\n <div id=\"subHeader_15\" class=\"form-subHeader\">\n If You Have Setup a Profile To Use, You Can Skip To The \"Profile This Order\" Box Below.\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_16\">\n <label class=\"form-label-top\" id=\"label_16\" for=\"input_16\"> Orthotic Shell Type <\/label>\n <div id=\"cid_16\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_16\" name=\"q16_orthoticShell\">\n <option> <\/option>\n <option value=\"EVA 35- SOFT\"> EVA 35- SOFT <\/option>\n <option value=\"EVA 45- MEDIUM\"> EVA 45- MEDIUM <\/option>\n <option value=\"EVA 50- FIRM\"> EVA 50- FIRM <\/option>\n <option value=\"Cork\"> Cork <\/option>\n <option value=\"Poly-Propylene \"> Poly-Propylene <\/option>\n <option value=\"Sub-Ortholene HDPE\"> Sub-Ortholene HDPE <\/option>\n <option value=\"Graphite\"> Graphite <\/option>\n <option value=\"Other\"> Other <\/option>\n <option selected=\"selected\" value=\"Select\"> Select <\/option>\n <option value=\"Lab Descretion\"> Lab Descretion <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_17\">\n <label class=\"form-label-top\" id=\"label_17\" for=\"input_17\"> Shell Width\/Style <\/label>\n <div id=\"cid_17\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_17\" name=\"q17_shellWidthstyle\">\n <option> <\/option>\n <option value=\"Narrow (Inside 1 and 5 mets)\"> Narrow (Inside 1 and 5 mets) <\/option>\n <option selected=\"selected\" value=\"Standard (Bisect 1\/Outside 5) \"> Standard (Bisect 1\/Outside 5) <\/option>\n <option value=\"Wide (Outside 1 and 5)\"> Wide (Outside 1 and 5) <\/option>\n <option value=\"DSIS Dynamic Stabilizing Cut Out\"> DSIS Dynamic Stabilizing Cut Out <\/option>\n <option value=\"Cobra Dress Pump Orthotic Cut Out\"> Cobra Dress Pump Orthotic Cut Out <\/option>\n <option value=\"UCBL\"> UCBL <\/option>\n <option value=\"Other \"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_18\">\n <label class=\"form-label-top\" id=\"label_18\" for=\"input_18\"> Heel Depth <\/label>\n <div id=\"cid_18\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_18\" name=\"q18_heelDepth\">\n <option> <\/option>\n <option selected=\"selected\" value=\"Standard 12-15 mm\"> Standard 12-15 mm <\/option>\n <option value=\"Low 8-10 mm\"> Low 8-10 mm <\/option>\n <option value=\"Deep 16-18 mm\"> Deep 16-18 mm <\/option>\n <option value=\"UCBL 20-24 mm\"> UCBL 20-24 mm <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_50\">\n <label class=\"form-label-top\" id=\"label_50\" for=\"input_50\"> Shell Rigidity <\/label>\n <div id=\"cid_50\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_50\" name=\"q50_shellRigidity50\">\n <option> <\/option>\n <option value=\"Accommodate only\"> Accommodate only <\/option>\n <option value=\"Flexible\"> Flexible <\/option>\n <option value=\"Semi-Rigid\"> Semi-Rigid <\/option>\n <option value=\"Rigid\"> Rigid <\/option>\n <option value=\"Very rigid\"> Very rigid <\/option>\n <option selected=\"selected\" value=\"Select\"> Select <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_19\">\n <label class=\"form-label-top\" id=\"label_19\" for=\"input_19\"> Met Pads <\/label>\n <div id=\"cid_19\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_19\" name=\"q19_metPads19\">\n <option> <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <option value=\"Bi-Lateral \"> Bi-Lateral <\/option>\n <option value=\"Right Only \"> Right Only <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_20\">\n <label class=\"form-label-top\" id=\"label_20\" for=\"input_20\"> Met Details <\/label>\n <div id=\"cid_20\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_20\" name=\"q20_metDetails20\">\n <option> <\/option>\n <option value=\"Medium-Soft (Standard)\"> Medium-Soft (Standard) <\/option>\n <option value=\"Medium-Firm\"> Medium-Firm <\/option>\n <option value=\"Low- Soft\"> Low- Soft <\/option>\n <option value=\"Low-Firm\"> Low-Firm <\/option>\n <option value=\"High-Soft\"> High-Soft <\/option>\n <option value=\"High-Firm\"> High-Firm <\/option>\n <option selected=\"selected\" value=\"None Selected\"> None Selected <\/option>\n <option value=\"Other\"> Other <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_21\">\n <label class=\"form-label-top\" id=\"label_21\" for=\"input_21\"> Heel Spur Pad \"U\" <\/label>\n <div id=\"cid_21\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_21\" name=\"q21_heelSpur\">\n <option> <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <option value=\"Right Only\"> Right Only <\/option>\n <option value=\"Bi-Lateral\"> Bi-Lateral <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_22\">\n <label class=\"form-label-top\" id=\"label_22\" for=\"input_22\"> Full Heel Cushion <\/label>\n <div id=\"cid_22\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_22\" name=\"q22_fullHeel\">\n <option> <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <option value=\"Right Only\"> Right Only <\/option>\n <option value=\"Bi=Lateral\"> Bi=Lateral <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_23\">\n <label class=\"form-label-top\" id=\"label_23\" for=\"input_23\"> Morton's Extension <\/label>\n <div id=\"cid_23\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_23\" name=\"q23_mortonsExtension\">\n <option> <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <option value=\"Right Only\"> Right Only <\/option>\n <option value=\"Bi-Lateral\"> Bi-Lateral <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_24\">\n <label class=\"form-label-top\" id=\"label_24\" for=\"input_24\"> Reverse Morton's <\/label>\n <div id=\"cid_24\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_24\" name=\"q24_reverseMortons24\">\n <option> <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <option value=\"Right Only\"> Right Only <\/option>\n <option value=\"Bi-Lateral\"> Bi-Lateral <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_25\">\n <label class=\"form-label-top\" id=\"label_25\" for=\"input_25\"> 1st Met Cutout <\/label>\n <div id=\"cid_25\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_25\" name=\"q25_1stMet25\">\n <option> <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <option value=\"Right Only\"> Right Only <\/option>\n <option value=\"Bi-Lateral \"> Bi-Lateral <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_27\">\n <label class=\"form-label-top\" id=\"label_27\" for=\"input_27\"> 1st RAY Cutout <\/label>\n <div id=\"cid_27\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_27\" name=\"q27_1stRay\">\n <option> <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <option value=\"Left Only\"> Left Only <\/option>\n <option value=\"Right Only\"> Right Only <\/option>\n <option value=\"Bi-Lateral\"> Bi-Lateral <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_28\">\n <label class=\"form-label-top\" id=\"label_28\" for=\"input_28\"> Heel Post Method <\/label>\n <div id=\"cid_28\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:145px\" id=\"input_28\" name=\"q28_heelPost\">\n <option> <\/option>\n <option value=\"Lab Discretion\"> Lab Discretion <\/option>\n <option value=\"Intrinsic\"> Intrinsic <\/option>\n <option value=\"Extrinsic\"> Extrinsic <\/option>\n <option value=\"Squared 0 degrees Extrinsic\"> Squared 0 degrees Extrinsic <\/option>\n <option value=\"Squared 0 degrees Intrinsic\"> Squared 0 degrees Intrinsic <\/option>\n <option value=\"Lateral Flare\"> Lateral Flare <\/option>\n <option value=\"Lateral Extension (reverse Thomas)\"> Lateral Extension (reverse Thomas) <\/option>\n <option selected=\"selected\" value=\"Neutral to cast\"> Neutral to cast <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_29\">\n <label class=\"form-label-top\" id=\"label_29\" for=\"input_29\"> Heel Post Bias <\/label>\n <div id=\"cid_29\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_29_0\" name=\"q29_heelPost29[]\" value=\"Medial\/Varus\" \/>\n <label for=\"input_29_0\"> Medial\/Varus <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_29_1\" name=\"q29_heelPost29[]\" value=\"Lateral\/Valgus\" \/>\n <label for=\"input_29_1\"> Lateral\/Valgus <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_30\">\n <label class=\"form-label-top\" id=\"label_30\" for=\"input_30\"> Rt Heel Post Amt. <\/label>\n <div id=\"cid_30\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_30\" name=\"q30_rtHeel30\" size=\"16\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_33\">\n <label class=\"form-label-top\" id=\"label_33\" for=\"input_33\"> Left Heel Post Amt. <\/label>\n <div id=\"cid_33\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_33\" name=\"q33_leftHeel\" size=\"16\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_31\">\n <label class=\"form-label-top\" id=\"label_31\" for=\"input_31\"> Forefoot Posting <\/label>\n <div id=\"cid_31\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:145px\" id=\"input_31\" name=\"q31_forefootPosting\">\n <option> <\/option>\n <option value=\"Lab Discretion\"> Lab Discretion <\/option>\n <option value=\"Intrinsic\"> Intrinsic <\/option>\n <option value=\"Extrinsic\"> Extrinsic <\/option>\n <option selected=\"selected\" value=\"Neutral to cast\"> Neutral to cast <\/option>\n <option value=\"Balance to heel\"> Balance to heel <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_32\">\n <label class=\"form-label-top\" id=\"label_32\" for=\"input_32\"> FFoot Post Bias <\/label>\n <div id=\"cid_32\" class=\"form-input-wide\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_32_0\" name=\"q32_ffootPost[]\" value=\"Medial\/Varus\" \/>\n <label for=\"input_32_0\"> Medial\/Varus <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_32_1\" name=\"q32_ffootPost[]\" value=\"Lateral\/Valgus\" \/>\n <label for=\"input_32_1\"> Lateral\/Valgus <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_34\">\n <label class=\"form-label-top\" id=\"label_34\" for=\"input_34\"> Right FF Post Amt. <\/label>\n <div id=\"cid_34\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_34\" name=\"q34_rightFf34\" size=\"16\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_35\">\n <label class=\"form-label-top\" id=\"label_35\" for=\"input_35\"> Left FF Post Amt. <\/label>\n <div id=\"cid_35\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_35\" name=\"q35_leftFf\" size=\"16\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column form-line-column-clear\" id=\"id_36\">\n <label class=\"form-label-top\" id=\"label_36\" for=\"input_36\"> Cover Length <\/label>\n <div id=\"cid_36\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_36\" name=\"q36_coverLength36\">\n <option> <\/option>\n <option value=\"Same as Shell 3\/4\"> Same as Shell 3\/4 <\/option>\n <option value=\"To Sulcus 7\/8\"> To Sulcus 7\/8 <\/option>\n <option value=\"No cover\"> No cover <\/option>\n <option selected=\"selected\" value=\"Full Length\"> Full Length <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_37\">\n <label class=\"form-label-top\" id=\"label_37\" for=\"input_37\"> Cover Material <\/label>\n <div id=\"cid_37\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_37\" name=\"q37_coverMaterial\">\n <option> <\/option>\n <option value=\"EVA 1\/16"\"> EVA 1\/16\" <\/option>\n <option value=\"EVA 1\/8"\"> EVA 1\/8\" <\/option>\n <option value=\"Spenco 1\/16"\"> Spenco 1\/16\" <\/option>\n <option value=\"Spenco 1\/8"\"> Spenco 1\/8\" <\/option>\n <option value=\"Vinyl\"> Vinyl <\/option>\n <option value=\"Plastazote 1\/8"\"> Plastazote 1\/8\" <\/option>\n <option value=\"Plastazote 3\/16"\"> Plastazote 3\/16\" <\/option>\n <option value=\"None\"> None <\/option>\n <option selected=\"selected\" value=\"Lab Discretion\"> Lab Discretion <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_38\">\n <label class=\"form-label-top\" id=\"label_38\" for=\"input_38\"> Extra Cushion <\/label>\n <div id=\"cid_38\" class=\"form-input-wide\">\n <select class=\"form-dropdown\" style=\"width:143px\" id=\"input_38\" name=\"q38_extraCushion\">\n <option> <\/option>\n <option value=\"PPT 1\/16" Full Length\"> PPT 1\/16\" Full Length <\/option>\n <option value=\"PPT 1\/16" Under Forefoot\"> PPT 1\/16\" Under Forefoot <\/option>\n <option value=\"PPT 1\/16" Length of Shell\"> PPT 1\/16\" Length of Shell <\/option>\n <option value=\"PPT 1\/16" To Sulcus\"> PPT 1\/16\" To Sulcus <\/option>\n <option value=\"PPT 1\/8" Full Length\"> PPT 1\/8\" Full Length <\/option>\n <option value=\"PPT 1\/8" Under Forefoot\"> PPT 1\/8\" Under Forefoot <\/option>\n <option value=\"PPT 1\/8" Length of Shell\"> PPT 1\/8\" Length of Shell <\/option>\n <option value=\"PPT 1\/8" To Sulcus\"> PPT 1\/8\" To Sulcus <\/option>\n <option value=\"EVA 1\/16" Full Length\"> EVA 1\/16\" Full Length <\/option>\n <option value=\"EVA 1\/16" Under Forefoot\"> EVA 1\/16\" Under Forefoot <\/option>\n <option value=\"EVA 1\/16" Length of Shell\"> EVA 1\/16\" Length of Shell <\/option>\n <option value=\"EVA 1\/16" To Sulcus\"> EVA 1\/16\" To Sulcus <\/option>\n <option value=\"EVA 1\/8" Full Length\"> EVA 1\/8\" Full Length <\/option>\n <option value=\"EVA 1\/8" Under Forefoot\"> EVA 1\/8\" Under Forefoot <\/option>\n <option value=\"EVA 1\/8" Length of Shell\"> EVA 1\/8\" Length of Shell <\/option>\n <option value=\"EVA 1\/8" To Sulcus\"> EVA 1\/8\" To Sulcus <\/option>\n <option selected=\"selected\" value=\"None (Standard)\"> None (Standard) <\/option>\n <\/select>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_26\">\n <label class=\"form-label-top\" id=\"label_26\" for=\"input_26\"> Heel Lift <\/label>\n <div id=\"cid_26\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_26\" name=\"q26_heelLift26\" size=\"16\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_39\">\n <label class=\"form-label-left\" id=\"label_39\" for=\"input_39\"> Additional Instructions And\/Or Request for Supplies <\/label>\n <div id=\"cid_39\" class=\"form-input\">\n <textarea id=\"input_39\" class=\"form-textarea\" name=\"q39_additionalInstructions\" cols=\"65\" rows=\"3\"><\/textarea>\n <\/div>\n <\/li>\n <li id=\"cid_45\" class=\"form-input-wide\">\n <div class=\"form-header-group\">\n <h2 id=\"header_45\" class=\"form-header\">\n Cast Delivery\n <\/h2>\n <div id=\"subHeader_45\" class=\"form-subHeader\">\n PLEASE CHOOSE YOUR METHOD OF DELIVERY TO LAB\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_47\">\n <label class=\"form-label-top\" id=\"label_47\" for=\"input_47\"> Date Submitted <\/label>\n <div id=\"cid_47\" class=\"form-input-wide\"><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"month_47\" name=\"q47_dateSubmitted[month]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"02\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"month_47\" id=\"sublabel_month\"> Month <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"day_47\" name=\"q47_dateSubmitted[day]\" type=\"text\" size=\"2\" maxlength=\"2\" value=\"08\" \/><span class=\"date-separate\"> -<\/span>\n <label class=\"form-sub-label\" for=\"day_47\" id=\"sublabel_day\"> Day <\/label><\/span><span class=\"form-sub-label-container\"><input class=\"form-textbox\" id=\"year_47\" name=\"q47_dateSubmitted[year]\" type=\"text\" size=\"4\" maxlength=\"4\" value=\"2012\" \/>\n <label class=\"form-sub-label\" for=\"year_47\" id=\"sublabel_year\"> Year <\/label><\/span><span class=\"form-sub-label-container\"><img alt=\"Pick a Date\" id=\"input_47_pick\" src=\"http:\/\/www.jotform.com\/images\/calendar.png\" align=\"absmiddle\" \/>\n <label class=\"form-sub-label\" for=\"input_47_pick\"> <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_51\">\n <label class=\"form-label-top\" id=\"label_51\" for=\"input_51\"> New or Existing Profile <\/label>\n <div id=\"cid_51\" class=\"form-input-wide\">\n <input type=\"text\" class=\"form-textbox\" id=\"input_51\" name=\"q51_newOr\" size=\"55\" \/>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_41\">\n <label class=\"form-label-left\" id=\"label_41\" for=\"input_41\"> UPLOAD ZIP FILE <\/label>\n <div id=\"cid_41\" class=\"form-input\"><span class=\"form-sub-label-container\"><div class=\"qq-uploader-buttonText-value\">\n Upload a File\n <\/div>\n <input class=\"form-upload-multiple\" type=\"file\" id=\"input_41\" name=\"q41_uploadZip41[]\" multiple=\"multiple\" file-accept=\"zip, doc, rar, pdf, jpg, stl, obj, wrl, vgg, txt\" file-maxsize=\"10000\" \/>\n <label class=\"form-sub-label\" for=\"input_41\"> Multiple files can be attached or zip all into one! <\/label><\/span>\n <\/div>\n <\/li>\n <li class=\"form-line form-line-column\" id=\"id_46\">\n <label class=\"form-label-right\" id=\"label_46\" for=\"input_46\"> Physical Delivery Options <\/label>\n <div id=\"cid_46\" class=\"form-input\">\n <div class=\"form-single-column\"><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_46_0\" name=\"q46_physicalDelivery46[]\" value=\"FREE Pick-Up in Knoxville, TN Area\" \/>\n <label for=\"input_46_0\"> FREE Pick-Up in Knoxville, TN Area <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_46_1\" name=\"q46_physicalDelivery46[]\" value=\"Email Mailing\/UPS label to above\" \/>\n <label for=\"input_46_1\"> Email Mailing\/UPS label to above <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_46_2\" name=\"q46_physicalDelivery46[]\" value=\"Practitioner handling delivery\" \/>\n <label for=\"input_46_2\"> Practitioner handling delivery <\/label><\/span><span class=\"clearfix\"><\/span><span class=\"form-checkbox-item\" style=\"clear:left;\"><input type=\"checkbox\" class=\"form-checkbox\" id=\"input_46_3\" name=\"q46_physicalDelivery46[]\" value=\"Call me to discuss pickup options\" \/>\n <label for=\"input_46_3\"> Call me to discuss pickup options <\/label><\/span><span class=\"clearfix\"><\/span>\n <\/div>\n <\/div>\n <\/li>\n <li class=\"form-line\" id=\"id_40\">\n <div id=\"cid_40\" class=\"form-input-wide\">\n <div style=\"margin-left:146px\" class=\"form-buttons-wrapper\">\n <button id=\"input_40\" type=\"submit\" class=\"form-submit-button\">\n Submit Form\n <\/button>\n \n <button id=\"input_print_40\" style=\"margin-left:25px;\" class=\"form-submit-print\" type=\"button\">\n <img src=\"http:\/\/www.jotform.com\/images\/printer.png\" align=\"absmiddle\" \/>\n Print Form\n <\/button>\n <\/div>\n <\/div>\n <\/li>\n <li style=\"display:none\">\n Should be Empty:\n <input type=\"text\" name=\"website\" value=\"\" \/>\n <\/li>\n <\/ul>\n <\/div>\n <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"1221251269\" \/>\n <script type=\"text\/javascript\">\n document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"1221251269-1221251269\";\n <\/script>\n<\/form><\/body>\n<\/html>\n");