wlhecapknso.com Open in urlscan Pro
2606:4700:3030::6815:44ef  Public Scan

Form analysis
1 forms found in the DOM

POST /flow?uid=c83bbe9d-7528-4063-97c1-bd19deeec1c2

<form id="formSubmit" action="/flow?uid=c83bbe9d-7528-4063-97c1-bd19deeec1c2" method="POST" data-effect="" data-effect-duration="">
  <div id="f1" class="dynamic-form form-step form1 form1-1">
    <div class="row row-spacing" data-row-id="1">
      <div id="col-field-html" class="col html form-field-col-ignored" data-col-id="1" data-autohide="">
        <div id="path-field-html-1-1-1" class="path-dynamic-field">
          <div style="font-weight:bold;margin-bottom:10px;">“*” indicates required fields</div>
        </div>
        <script>
          document.querySelector('#path-field-html-1-1-1').addEventListener('path-dynamic-field-register', function(evt) {
            var elem = this
            elem.fieldContent = elem.innerHTML
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillMergetagsHTML(elem)
                },
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="2">
      <div id="col-field-first_name" class="col first-name form-field-col" data-col-id="1" data-autohide="">
        <label class="label">* First Name</label>
        <input id="first_name" type="text" name="first_name" class="path-form-field-with-feedback path-dynamic-field required" title="First Name" value="">
        <span id="first_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#first_name').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#first_name-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6eyJhY3Rpb25zIjpbXSwicGxhY2Vob2xkZXIiOiIifSwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('first_name')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
      <div id="col-field-last_name" class="col last-name form-field-col" data-col-id="2" data-autohide="">
        <label class="label">* Last Name</label>
        <input id="last_name" type="text" name="last_name" class="path-form-field-with-feedback path-dynamic-field required" title="Last Name" value="">
        <span id="last_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#last_name').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#last_name-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('last_name')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="3">
      <div id="col-field-cf_job_title_ha_freechip" class="col select-job-title-ha-freechip form-field-col" data-col-id="1" data-autohide="">
        <label class="label">* Job Title</label>
        <select id="cf_job_title_ha_freechip" data-custom="cf_job_title_ha_freechip" name="cf_job_title_ha_freechip" title="* Job Title" class="path-form-field-with-feedback path-dynamic-field required">
          <option value=""> Select Option </option>
          <option value="FrontOfficeStaff">Front Office Staff</option>
          <option value="OfficePracticeManager">Office/Practice Manager</option>
          <option value="OwnerPrincipal">Owner/Principal</option>
          <option value="Purchaser">Purchaser</option>
          <option value="Retailer">Retailer</option>
          <option value="VetStudent">Vet Student</option>
          <option value="Veterinarian">Veterinarian</option>
          <option value="Other">Other</option>
        </select>
        <span id="cf_job_title_ha_freechip-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#cf_job_title_ha_freechip').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#cf_job_title_ha_freechip-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.overrideOnChangeListener(function() {
              elem.addEventListener('change', evt.detail.listener(function(evt, setValue) {
                setValue(evt.target.value)
              }))
            })
            evt.detail.setFieldOptions(
              '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%3D'
              )
            evt.detail.assignToState('cf_job_title_ha_freechip')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  populate_options: renders.fillSelectOptions(elem, `
                Select Option
          `),
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="4">
      <div id="col-field-email" class="col e-mail-required form-field-col" data-col-id="1" data-autohide="">
        <label class="label">* E-mail</label>
        <input id="email" list="email_domains" type="email" name="email" class="path-form-field-with-feedback path-dynamic-field required" title="Email" data-session-verification="-1" value="">
        <span id="emailmessage" class="invalid-feedback hidden path-form-feedback"></span>
        <datalist id="email_domains"></datalist>
        <script>
          document.querySelector('#email').addEventListener('path-dynamic-field-register', function(evt) {
            var domains = ["gmail.com", "yahoo.com", "hotmail.com", "aol.com", "hotmail.co.uk", "hotmail.fr", "msn.com", "yahoo.fr", "wanadoo.fr", "orange.fr", "comcast.net", "yahoo.co.uk", "yahoo.co.in", "live.com", "rediffmail.com", "free.fr",
              "gmx.de", "web.de", "yandex.ru", "ymail.com", "libero.it", "outlook.com", "uol.com", "bol.com", "mail.ru", "cox.net", "hotmail.it", "sbcglobal.net", "sfr.fr", "live.fr", "verizon.net", "live.co.uk", "googlemail.com", "yahoo.es",
              "ig.com", "live.nl", "bigpond.com", "terra.com", "yahoo.it", "neuf.fr", "yahoo.de", "alice.it", "rocketmail.com", "att.net", "laposte.net", "facebook.com", "bellsouth.net", "yahoo.in", "hotmail.es", "charter.net", "yahoo.ca",
              "yahoo.com.au", "rambler.ru", "hotmail.de", "tiscali.it", "shaw.ca", "yahoo.co.jp", "sky.com"
            ]
            var feedbackElem = document.querySelector('#emailmessage')
            var emailDomains = document.querySelector('#email_domains')
            var elem = this
            evt.detail.overrideOnChangeListener(function() {
              elem.addEventListener('input', evt.detail.listener(function(evt, setValue) {
                var value = evt.target.value
                setValue(value)
                var split = value.split('@')
                var username = split[0]
                var domain = split[1]
                var regex = domain && new RegExp('@' + domain)
                emailDomains.innerHTML = ''
                domains.forEach(function(domain) {
                  if (regex && regex.test('@' + domain) && username + '@' + domain !== value) {
                    var option = emailDomains.appendChild(document.createElement('option'))
                    option.setAttribute('value', username + '@' + domain)
                  }
                })
              }))
            })
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('test')
            evt.detail.assignToState('email', evt.detail.effects.test)
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
      <div id="col-field-phone" class="col phone form-field-col" data-col-id="2" data-autohide="">
        <label class="label">* Mobile Phone</label>
        <input id="phone" type="tel" name="phone" title="Phone" data-session-verification="-1" value="" class="path-dynamic-field path-form-field-with-feedback required" pattern="[0-9]*" inputmode="numeric" autocomplete="tel-national">
        <span id="phone-error-feedback" class="invalid-feedback hidden path-form-feedback invalid-phone"></span>
        <script>
          document.querySelector('#phone').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#phone-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('phone')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInputPhone(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="5">
      <div id="col-field-html" class="col html form-field-col-ignored" data-col-id="1" data-autohide="">
        <div id="path-field-html-1-5-1" class="path-dynamic-field">
          <div style="font-size:16px;font-weight:bold;border-bottom:1px solid #ccc;margin:10px auto 10px auto;">Business Information</div>
        </div>
        <script>
          document.querySelector('#path-field-html-1-5-1').addEventListener('path-dynamic-field-register', function(evt) {
            var elem = this
            elem.fieldContent = elem.innerHTML
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOm51bGx9')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillMergetagsHTML(elem)
                },
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="6">
      <div id="col-field-cf_business_name" class="col input-business-name form-field-col" data-col-id="1" data-autohide="">
        <label class="label">* Business Name</label>
        <div class="cf_text">
          <label class="cf_text__label" for="cf_business_name_0">
            <input class="cf_text__input path-dynamic-field path-form-field-with-feedback required" type="text" data-custom="cf_business_name" name="cf_business_name" id="cf_business_name_0" value="">
            <span id="cf_business_name-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
          </label>
        </div>
        <script>
          document.querySelector('#cf_business_name_0').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#cf_business_name-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('cf_business_name')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="7">
      <div id="col-field-zip" class="col zip-code form-field-col" data-col-id="1" data-autohide="">
        <label class="label">* Business Zip Code</label>
        <input id="zip" type="text" name="zip" title="Zipcode" maxlength="5" data-session-verification="-1" value="" class="path-form-field-with-feedback required path-dynamic-field" pattern="[0-9]*" inputmode="numeric" autocomplete="postal-code">
        <span id="zip-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#zip').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#zip-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('zip')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillZip(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
            $(elem).change()
          })
        </script>
      </div>
      <div id="col-field-state" class="col state form-field-col" data-col-id="2" data-autohide="">
        <label class="label">* Business State</label>
        <select id="state" name="state" title="State" class="path-form-field-with-feedback path-dynamic-field required" value="" datavalue="">
          <option value=""> Select State </option>
          <option value="AL">Alabama</option>
          <option value="AK">Alaska</option>
          <option value="AZ">Arizona</option>
          <option value="AR">Arkansas</option>
          <option value="CA">California</option>
          <option value="CO">Colorado</option>
          <option value="CT">Connecticut</option>
          <option value="DE">Delaware</option>
          <option value="DC">District Of Columbia</option>
          <option value="FL">Florida</option>
          <option value="GA">Georgia</option>
          <option value="HI">Hawaii</option>
          <option value="ID">Idaho</option>
          <option value="IL">Illinois</option>
          <option value="IN">Indiana</option>
          <option value="IA">Iowa</option>
          <option value="KS">Kansas</option>
          <option value="KY">Kentucky</option>
          <option value="LA">Louisiana</option>
          <option value="ME">Maine</option>
          <option value="MD">Maryland</option>
          <option value="MA">Massachusetts</option>
          <option value="MI">Michigan</option>
          <option value="MN">Minnesota</option>
          <option value="MS">Mississippi</option>
          <option value="MO">Missouri</option>
          <option value="MT">Montana</option>
          <option value="NE">Nebraska</option>
          <option value="NV">Nevada</option>
          <option value="NH">New Hampshire</option>
          <option value="NJ">New Jersey</option>
          <option value="NM">New Mexico</option>
          <option value="NY">New York</option>
          <option value="NC">North Carolina</option>
          <option value="ND">North Dakota</option>
          <option value="OH">Ohio</option>
          <option value="OK">Oklahoma</option>
          <option value="OR">Oregon</option>
          <option value="PA">Pennsylvania</option>
          <option value="RI">Rhode Island</option>
          <option value="SC">South Carolina</option>
          <option value="SD">South Dakota</option>
          <option value="TN">Tennessee</option>
          <option value="TX">Texas</option>
          <option value="UT">Utah</option>
          <option value="VT">Vermont</option>
          <option value="VA">Virginia</option>
          <option value="WA">Washington</option>
          <option value="WV">West Virginia</option>
          <option value="WI">Wisconsin</option>
          <option value="WY">Wyoming</option>
        </select>
        <span id="state-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#state').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#state-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('state')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  populate_options: renders.fillSelectOptions(elem, `
                Select State
          `),
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="8">
      <div id="col-field-cf_business_type_ha_freechip" class="col select-business-type-ha-freechip form-field-col" data-col-id="1" data-autohide="">
        <label class="label">* Business Type</label>
        <select id="cf_business_type_ha_freechip" data-custom="cf_business_type_ha_freechip" name="cf_business_type_ha_freechip" title="* Business Type" class="path-form-field-with-feedback path-dynamic-field required">
          <option value=""> Select Option </option>
          <option value="ClinicHospital">Clinic/Hospital</option>
          <option value="Shelter">Shelter</option>
          <option value="Rescue">Rescue</option>
          <option value="Other">Other</option>
        </select>
        <span id="cf_business_type_ha_freechip-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
        <script>
          document.querySelector('#cf_business_type_ha_freechip').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#cf_business_type_ha_freechip-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.overrideOnChangeListener(function() {
              elem.addEventListener('change', evt.detail.listener(function(evt, setValue) {
                setValue(evt.target.value)
              }))
            })
            evt.detail.setFieldOptions(
              'W3sibGFiZWwiOiJDbGluaWMvSG9zcGl0YWwiLCJ2YWx1ZSI6IkNsaW5pY0hvc3BpdGFsIn0seyJsYWJlbCI6IlNoZWx0ZXIiLCJ2YWx1ZSI6IlNoZWx0ZXIifSx7ImxhYmVsIjoiUmVzY3VlIiwidmFsdWUiOiJSZXNjdWUifSx7ImxhYmVsIjoiT3RoZXIiLCJ2YWx1ZSI6Ik90aGVyIn1d')
            evt.detail.assignToState('cf_business_type_ha_freechip')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  populate_options: renders.fillSelectOptions(elem, `
                Select Option
          `),
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
      <div id="col-field-cf_business_phone" class="col input-business-phone form-field-col" data-col-id="2" data-autohide="">
        <label class="label">* Business Phone</label>
        <div class="cf_text">
          <label class="cf_text__label" for="cf_business_phone_1">
            <input class="cf_text__input path-dynamic-field path-form-field-with-feedback required" type="text" data-custom="cf_business_phone" name="cf_business_phone" id="cf_business_phone_1" value="">
            <span id="cf_business_phone-error-feedback" class="invalid-feedback hidden path-form-feedback"></span>
          </label>
        </div>
        <script>
          document.querySelector('#cf_business_phone_1').addEventListener('path-dynamic-field-register', function(evt) {
            var feedbackElem = document.querySelector('#cf_business_phone-error-feedback')
            var elem = this
            evt.detail.setControls('eyJwb3B1bGF0ZSI6bnVsbCwidmlzaWJpbGl0eSI6bnVsbCwidmFsaWRhdGlvbnMiOnsiYWN0aW9ucyI6W10sInJlcXVpcmVkIjp0cnVlfX0%3D')
            evt.detail.assignToState('cf_business_phone')
            evt.detail.render(function(renders) {
              return {
                hide: renders.hideParentFieldForm(elem),
                show: renders.hideParentFieldForm(elem, false),
                populate: {
                  prepopulate_with: renders.fillInput(elem)
                },
                validation: renders.fillFeedbackMessage(feedbackElem)
              }
            })
          })
        </script>
      </div>
    </div>
    <div class="row row-spacing" data-row-id="9">
      <div id="col-field-registration_consent" class="col registration-consent form-field-col" data-col-id="1" data-autohide="false">
        <div class="terms termschk">
          <input type="checkbox" class="chkbox path-dynamic-field" id="chkterms" name="chkterms">
          <label class="term-label terms-label--checkbox" for="chkterms"> I am interested in receiving communications from Merck Animal Health and its subsidiaries on products, programs and scientific information. I can manage my communication
            preferences by clicking on the link at the bottom of my email at any time. </label>
          <script>
            document.querySelector('#chkterms').addEventListener('path-dynamic-field-register', function(evt) {
              var elem = this
              evt.detail.assignToState('registrationConsent', function(value) {
                elem.dispatchEvent(new CustomEvent('path-event-registration-consent-changed'))
                return elem.checked
              })
            })
          </script>
        </div>
      </div>
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