Contact us
{
parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-text"
as=${html``}
/>
<${props.Select}
className=${"mf-input mf-input-select " + ( validation.errors['country_code'] ? 'mf-invalid' : '' )}
classNamePrefix="mf_select"
name="country_code"
placeholder="${ parent.decodeEntities(`Select`) } "
isSearchable=${false}
options=${[{"label":"+91 - India","value":"+91","isDisabled":false},{"label":"+1 - USA","value":"+1","isDisabled":false},{"label":"+44 - United Kingdom","value":"+44","isDisabled":false}]}
value=${parent.getValue("country_code") ? [{"label":"+91 - India","value":"+91","isDisabled":false},{"label":"+1 - USA","value":"+1","isDisabled":false},{"label":"+44 - United Kingdom","value":"+44","isDisabled":false}].filter(item => item.value === parent.getValue("country_code"))[0] : []}
onChange=${(e)=> parent.handleSelect(e, "country_code")}
ref=${() => {
register({ name: "country_code" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":false}));
if ( parent.getValue("country_code") === '' && false ) {
parent.setValue( 'country_code', '', true );
parent.handleChange({
target: {
name: 'country_code',
value: ''
}
});
}
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="country_code"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","minLength":"","maxLength":10,"type":"by_character_length","required":true,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-telephone"
as=${html``}
/>
parent.activateValidation({"message":"This field is required.","emailMessage":"Please enter a valid Email address","minLength":1,"maxLength":"","type":"none","required":true,"expression":"null"}, el)}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-email"
as=${html``}
/>
<${props.Select}
className=${"mf-input mf-input-select " + ( validation.errors['mf-select'] ? 'mf-invalid' : '' )}
classNamePrefix="mf_select"
name="mf-select"
placeholder="${ parent.decodeEntities(`Specialties`) } "
isSearchable=${false}
options=${[{"label":"Podiatry","value":"value-1","isDisabled":false},{"label":"Oncology","value":"value-2","isDisabled":false},{"label":"Cardiology","value":"value-3","isDisabled":false},{"label":"Anesthesia","value":"value-4","isDisabled":false},{"label":"Neurology","value":"value-5","isDisabled":false},{"label":"Dermatology","value":"value-6","isDisabled":false},{"label":"Gastroenterology","value":"value-7","isDisabled":false},{"label":"Pain Management","value":"value-8","isDisabled":false},{"label":"Internal Medicine","value":"value-9","isDisabled":false},{"label":"Urology","value":"value-10","isDisabled":false},{"label":"Radiology","value":"value-11","isDisabled":false},{"label":"Mental Health","value":"value-12","isDisabled":false},{"label":"Family Medicine","value":"value-13","isDisabled":false},{"label":"OB\/GYN","value":"value-14","isDisabled":false},{"label":"Wound Care","value":"value-15","isDisabled":false},{"label":"Skilled Nursing Facility","value":"value-16","isDisabled":false},{"label":"ASC","value":"value-17","isDisabled":false},{"label":"Home Health","value":"value-18","isDisabled":false},{"label":"Orthopedics","value":"value-19","isDisabled":false},{"label":"DME","value":"value-20","isDisabled":false}]}
value=${parent.getValue("mf-select") ? [{"label":"Podiatry","value":"value-1","isDisabled":false},{"label":"Oncology","value":"value-2","isDisabled":false},{"label":"Cardiology","value":"value-3","isDisabled":false},{"label":"Anesthesia","value":"value-4","isDisabled":false},{"label":"Neurology","value":"value-5","isDisabled":false},{"label":"Dermatology","value":"value-6","isDisabled":false},{"label":"Gastroenterology","value":"value-7","isDisabled":false},{"label":"Pain Management","value":"value-8","isDisabled":false},{"label":"Internal Medicine","value":"value-9","isDisabled":false},{"label":"Urology","value":"value-10","isDisabled":false},{"label":"Radiology","value":"value-11","isDisabled":false},{"label":"Mental Health","value":"value-12","isDisabled":false},{"label":"Family Medicine","value":"value-13","isDisabled":false},{"label":"OB\/GYN","value":"value-14","isDisabled":false},{"label":"Wound Care","value":"value-15","isDisabled":false},{"label":"Skilled Nursing Facility","value":"value-16","isDisabled":false},{"label":"ASC","value":"value-17","isDisabled":false},{"label":"Home Health","value":"value-18","isDisabled":false},{"label":"Orthopedics","value":"value-19","isDisabled":false},{"label":"DME","value":"value-20","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select"))[0] : []}
onChange=${(e)=> parent.handleSelect(e, "mf-select")}
ref=${() => {
register({ name: "mf-select" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true}));
if ( parent.getValue("mf-select") === '' && false ) {
parent.setValue( 'mf-select', '', true );
parent.handleChange({
target: {
name: 'mf-select',
value: ''
}
});
}
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-select"
as=${html``}
/>
<${props.Select}
className=${"mf-input mf-input-select " + ( validation.errors['mf-select'] ? 'mf-invalid' : '' )}
classNamePrefix="mf_select"
name="mf-select"
placeholder="${ parent.decodeEntities(`Monthly Insurance Collection`) } "
isSearchable=${false}
options=${[{"label":"Start-Up","value":"value-1","isDisabled":false},{"label":"20,000$ - 50,000$","value":"value-2","isDisabled":false},{"label":"50,000$ - 1,00,000$","value":"value-3","isDisabled":false},{"label":"1,00,000$ - 5,00,000$","value":"value-4","isDisabled":false},{"label":"5,00,000$ - 1,000,000$","value":"value-5","isDisabled":false},{"label":"1,000,000$ - Above","value":"value-6","isDisabled":false}]}
value=${parent.getValue("mf-select") ? [{"label":"Start-Up","value":"value-1","isDisabled":false},{"label":"20,000$ - 50,000$","value":"value-2","isDisabled":false},{"label":"50,000$ - 1,00,000$","value":"value-3","isDisabled":false},{"label":"1,00,000$ - 5,00,000$","value":"value-4","isDisabled":false},{"label":"5,00,000$ - 1,000,000$","value":"value-5","isDisabled":false},{"label":"1,000,000$ - Above","value":"value-6","isDisabled":false}].filter(item => item.value === parent.getValue("mf-select"))[0] : []}
onChange=${(e)=> parent.handleSelect(e, "mf-select")}
ref=${() => {
register({ name: "mf-select" }, parent.activateValidation({"message":"This field is required.","minLength":1,"maxLength":"","type":"none","required":true}));
if ( parent.getValue("mf-select") === '' && false ) {
parent.setValue( 'mf-select', '', true );
parent.handleChange({
target: {
name: 'mf-select',
value: ''
}
});
}
}}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-select"
as=${html``}
/>
<${validation.ErrorMessage}
errors=${validation.errors}
name="mf-textarea"
as=${html``}
/>
