www.appointmentrsvp.com
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URL:
https://www.appointmentrsvp.com/
Submission: On December 14 via manual from AT — Scanned from AT
Submission: On December 14 via manual from AT — Scanned from AT
Form analysis 1 forms found in the DOM
POST /
<form method="post" enctype="multipart/form-data" id="gform_1" action="/" data-formid="1" novalidate="">
<div class="gform-body gform_body">
<div id="gform_fields_1" class="gform_fields top_label form_sublabel_below description_below">
<div id="field_1_1" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_1">
<h1 style="text-align: center;"><strong>Request a MERCK representative appointment</strong></h1>
<p class="comp" style="text-align: center;font-size:18px;margin-bottom:32px;">Complete the required fields below to request an appointment</p>
<script>
var inputElement = document.getElementById("input_1_9");
// Create a Date object for today's date
var today = new Date();
// Format the date as mm/dd/yyyy
var formattedDate = (today.getMonth() + 1) + '/' + today.getDate() + '/' + today.getFullYear();
// Set the formatted date as the input element's value
inputElement.value = formattedDate;
</script>
<script type="text/javascript">
gform.addFilter('gform_datepicker_options_pre_init', function(optionsObj, formId, fieldId) {
// Apply to field 2 only
if (fieldId == 9) {
optionsObj.minDate = 0;
}
return optionsObj;
});
</script>
</div>
<fieldset id="field_1_3" class="gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_3">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row" id="input_1_3">
<span id="input_1_3_3_container" class="name_first gform-grid-col gform-grid-col--size-auto">
<label for="input_1_3_3" class="gform-field-label gform-field-label--type-sub ">First name</label>
<input data-design-module="Form" data-design-category="Label" type="text" name="input_3.3" id="input_1_3_3" value="" aria-required="true">
</span>
<span id="input_1_3_6_container" class="name_last gform-grid-col gform-grid-col--size-auto">
<label for="input_1_3_6" class="gform-field-label gform-field-label--type-sub ">Last name</label>
<input data-design-module="Form" data-design-category="Label" type="text" name="input_3.6" id="input_1_3_6" value="" aria-required="true">
</span>
</div>
</fieldset>
<div id="field_1_16" class="gfield gfield--type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_16"><label
class="gfield_label gform-field-label" for="input_1_16">Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_phone"><input name="input_16" id="input_1_16" data-design-module="Form" data-design-category="Label" type="tel" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</div>
<div id="field_1_5" class="gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_5"><label
class="gfield_label gform-field-label" for="input_1_5">Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_5" id="input_1_5" data-design-module="Form" data-design-category="Label" type="email" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</div>
<fieldset id="field_1_19" class="gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_19">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Zip<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_complex ginput_container has_zip has_country ginput_container_address gform-grid-row" id="input_1_19">
<input data-design-module="Form" data-design-category="Label" type="hidden" class="gform_hidden" name="input_19.4" id="input_1_19_4" value=""><span class="ginput_right address_zip ginput_address_zip gform-grid-col"
id="input_1_19_5_container">
<input data-design-module="Form" data-design-category="Label" type="text" name="input_19.5" id="input_1_19_5" value="" aria-required="true">
<label for="input_1_19_5" id="input_1_19_5_label" class="gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text">ZIP Code</label>
</span><input data-design-module="Form" data-design-category="Label" type="hidden" class="gform_hidden" name="input_19.6" id="input_1_19_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</fieldset>
<fieldset id="field_1_7" class="gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_7">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Preferred contact<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_7">
<div class="gchoice gchoice_1_7_1">
<input class="gfield-choice-input" name="input_7.1" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Email" id="choice_1_7_1">
<label for="choice_1_7_1" id="label_1_7_1" class="gform-field-label gform-field-label--type-inline">Email</label>
</div>
<div class="gchoice gchoice_1_7_2">
<input class="gfield-choice-input" name="input_7.2" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Phone" id="choice_1_7_2">
<label for="choice_1_7_2" id="label_1_7_2" class="gform-field-label gform-field-label--type-inline">Phone</label>
</div>
<div class="gchoice gchoice_1_7_3">
<input class="gfield-choice-input" name="input_7.3" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Office visit" id="choice_1_7_3">
<label for="choice_1_7_3" id="label_1_7_3" class="gform-field-label gform-field-label--type-inline">Office visit</label>
</div>
<div class="gchoice gchoice_1_7_4">
<input class="gfield-choice-input" name="input_7.4" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Online meeting" id="choice_1_7_4">
<label for="choice_1_7_4" id="label_1_7_4" class="gform-field-label gform-field-label--type-inline">Online meeting</label>
</div>
</div>
</div>
</fieldset>
<fieldset id="field_1_8" class="gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_8">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Service request</legend>
<div class="ginput_container ginput_container_checkbox">
<div class="gfield_checkbox" id="input_1_8">
<div class="gchoice gchoice_1_8_1">
<input class="gfield-choice-input" name="input_8.1" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Introduction" id="choice_1_8_1">
<label for="choice_1_8_1" id="label_1_8_1" class="gform-field-label gform-field-label--type-inline">Introduction</label>
</div>
<div class="gchoice gchoice_1_8_2">
<input class="gfield-choice-input" name="input_8.2" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Product information" id="choice_1_8_2">
<label for="choice_1_8_2" id="label_1_8_2" class="gform-field-label gform-field-label--type-inline">Product information</label>
</div>
<div class="gchoice gchoice_1_8_3">
<input class="gfield-choice-input" name="input_8.3" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Follow-up" id="choice_1_8_3">
<label for="choice_1_8_3" id="label_1_8_3" class="gform-field-label gform-field-label--type-inline">Follow-up</label>
</div>
<div class="gchoice gchoice_1_8_4">
<input class="gfield-choice-input" name="input_8.4" data-design-module="Form" data-design-category="checklist" type="checkbox" value="Others" id="choice_1_8_4">
<label for="choice_1_8_4" id="label_1_8_4" class="gform-field-label gform-field-label--type-inline">Others</label>
</div>
</div>
</div>
</fieldset>
<div id="field_1_9" class="gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible"
data-js-reload="field_1_9"><label class="gfield_label gform-field-label" for="input_1_9">Preferred contact date</label>
<div class="ginput_container ginput_container_date">
<input name="input_9" id="input_1_9" type="text" value="" class="datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon hasDatepicker initialized" placeholder="mm/dd/yyyy" aria-describedby="input_1_9_date_format"
aria-invalid="false"><img class="ui-datepicker-trigger" src="https://www.appointmentrsvp.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg" alt="Select date" title="Select date">
<span id="input_1_9_date_format" class="screen-reader-text">MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_1_9" class="gform_hidden" value="https://www.appointmentrsvp.com/wp-content/plugins/gravityforms/images/datepicker/datepicker.svg">
</div>
<fieldset id="field_1_10" class="gfield gfield--type-time gfield--width-half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_10">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Best time to contact</legend>
<div class="ginput_container ginput_complex gform-grid-row">
<div class="gfield_time_hour ginput_container ginput_container_time gform-grid-col" id="input_1_10">
<input type="number" maxlength="2" name="input_10[]" id="input_1_10_1" value="" min="0" max="12" step="1" placeholder="HH" aria-required="false">
<label class="gform-field-label gform-field-label--type-sub hour_label screen-reader-text" for="input_1_10_1">Hours</label>
</div>
<div class="below hour_minute_colon gform-grid-col">:</div>
<div class="gfield_time_minute ginput_container ginput_container_time gform-grid-col">
<input type="number" maxlength="2" name="input_10[]" id="input_1_10_2" value="" min="0" max="59" step="1" placeholder="MM" aria-required="false">
<label class="gform-field-label gform-field-label--type-sub minute_label screen-reader-text" for="input_1_10_2">Minutes</label>
</div>
<div class="gfield_time_ampm ginput_container ginput_container_time below gform-grid-col">
<div class="select-dropdown select-dropdown--0"><select name="input_10[]" id="input_1_10_3" style="display: none;">
<option value="am">AM</option>
<option value="pm">PM</option>
</select><button class="select-dropdown__button select-dropdown__button--0" data-value="" type="button"><span class="select-dropdown select-dropdown--0">AM</span><i class="arrow arrow-down"></i></button>
<ul class="select-dropdown__list select-dropdown__list--0" id="select-dropdown__list-0">
<li class="select-dropdown__list-item" data-value="am">AM</li>
<li class="select-dropdown__list-item" data-value="pm">PM</li>
</ul>
</div>
<label class="gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text" for="input_1_10_3">AM/PM</label>
</div>
</div>
</fieldset>
<div class="spacer gfield" style="grid-column: span 6;"></div>
<div id="field_1_21" class="gfield gfield--type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden" data-js-reload="field_1_21">
<div class="admin-hidden-markup"><i class="gform-icon gform-icon--hidden"></i><span>Hidden</span></div><label class="gfield_label gform-field-label" for="input_1_21">To Email</label>
<div class="ginput_container ginput_container_email">
<input name="input_21" id="input_1_21" data-design-module="Form" data-design-category="Label" type="email" value="" class="large" aria-invalid="false">
</div>
</div>
<div id="field_1_15" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible" data-js-reload="field_1_15">
<style>
.select-dropdown__button--0 {
min-height: 0rem !important;
}
#validation_message_1_16 {
display: none;
}
#field_1_14>div.ginput_container.ginput_container_consent {
display: flex !important;
}
#field_1_19>legend {
margin-bottom: 0.5rem !important;
}
.gform_wrapper.gravity-theme .gfield_required {
font-style: italic !important;
}
#field_1_10>legend {
margin-bottom: 0.5rem !important;
}
.ginput_complex label {
font-size: 16px !important;
}
.gfield_label {
font-size: 16px !important;
font-weight: 700 !important;
}
.gfield_label {
font-size: 16px !important;
font-weight: 700 !important;
}
.gform-field-label {
font-size: 16px !important;
}
.select-dropdown__button {
min-width: 4.5rem !important;
}
div[id*="gform_wrapper"] form input[type='checkbox']:after {
right: 9px !important;
}
div[id*="gform_wrapper"] form input[type='checkbox']:hover {
border: 1px solid var(--active);
}
.ginput_container_date input {
width: 360px !important;
}
#gform_submit_button_1 {
padding: 11px 50px !important;
}
.gform_submission_error {
font-size: 14px !important;
}
@media (max-width: 991px) {
#ui-datepicker-div {
transform: scale(0.75);
left: 5px !important;
}
#input_1_14_1 {
width: 1.963rem !important;
}
.gform_wrapper.gravity-theme .ginput_complex span,
.select-dropdown__button .arrow-down {
margin-bottom: 4px !important;
margin-top: 4px !important;
}
}
@media only screen and (max-width: 600px) {
#input_1_16 {
width: 100% !important;
}
#input_1_5 {
width: 100% !important;
}
#input_1_6 {
width: 100% !important;
}
#input_1_9 {
width: 100% !important;
}
.gform_button {
text-align: center;
}
.comp {
margin-bottom: 16px !important;
font-size: 16px !important;
}
}
</style>
<script type="text/javascript">
document.querySelector("#field_1_16 > div.ginput_container.ginput_container_phone > div").textContent = "Phone format: (###) ###-####. This field is required.";
</script>
<script>
// Find the existing viewport meta tag
const viewportMeta = document.querySelector('meta[name="viewport"]');
// Modify its content attribute
viewportMeta.setAttribute('content', 'width=device-width, initial-scale=1, maximum-scale=1, user-scalable=0');
</script>
</div>
<fieldset id="field_1_14"
class="gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full disFlex gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible"
data-js-reload="field_1_14">
<legend class="gfield_label gform-field-label gfield_label_before_complex">Consent<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></legend>
<div class="ginput_container ginput_container_consent"><input name="input_14.1" id="input_1_14_1" type="checkbox" value="1" aria-required="true" aria-invalid="false"> <label
class="gform-field-label gform-field-label--type-inline gfield_consent_label" for="input_1_14_1">I confirm that I am a health care professional<span class="gfield_required gfield_required_text">(Required)</span></label><input
type="hidden" name="input_14.2" value="I confirm that I am a health care professional" class="gform_hidden"><input type="hidden" name="input_14.3" value="1" class="gform_hidden"></div>
</fieldset>
</div>
</div>
<div class="gform_footer before"> <input data-design-module="Form" data-design-category="button" type="submit" id="gform_submit_button_1" class="gform_button button" value="Submit"
onclick="if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_1" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="1">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_1"
value="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">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_1" id="gform_target_page_number_1" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_1" id="gform_source_page_number_1" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js" value="1702572444269">
<script>
document.getElementById("ak_js_1").setAttribute("value", (new Date()).getTime());
</script>
</p>
</form>Text Content
Skip to main content Main menu ARE YOU A HEALTH CARE PROFESSIONAL? This section contains information intended for health care professionals in the United States only and is not intended for the general public. No, I am not. Please take me back. Yes, I am. This site is intended only for residents of the United States, its territories, and Puerto Rico. Copyright © 2022 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved. All rights reserved. CODE000000000-0000 00/00 TERMS AND CONDITIONS Close REQUEST A MERCK REPRESENTATIVE APPOINTMENT Complete the required fields below to request an appointment Name(Required) First name Last name Phone(Required) Email(Required) Zip(Required) ZIP Code Preferred contact(Required) Email Phone Office visit Online meeting Service request Introduction Product information Follow-up Others Preferred contact date MM slash DD slash YYYY Best time to contact Hours : Minutes AM PM AM * AM * PM AM/PM Hidden To Email Consent(Required) I confirm that I am a health care professional(Required) Δ BY CLICKING ON THIS LINK, YOU WILL BE LEAVING THIS SITE. This link will take you to a site outside Merck & Co., Inc. Merck does not review or control the content of any non-Merck site. Merck does not endorse and is not responsible for the accuracy, content, practices, or standards of any non-Merck site. Cancel Proceed Cancel Proceed TERMS AND CONDITIONS Close Follow us: * Privacy policy * Terms of use * Cookie preferences * Accessibility Copyright © 2023 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved. This site is intended only for residents of the United States and its territories, including Puerto Rico. US-NON-14509 11/23 Notifications This Site Uses Cookies and Your Privacy Choice Is Important to Us. Choose Customize My Settings to make your privacy choices. Choose Accept All Cookies to accept third-party cookies.See our Privacy Policy Customize My Settings Accept All Cookies