if (window.location.protocol != "https:" && window.location.href.indexOf("formulate") == -1 && "False" === "True") { window.location.href = "https:" + window.location.href.substring(window.location.protocol.length); } var fbScriptTag = document.getElementsByClassName("d187c175-c567-4374-a612-0908106cdd99"), fbBodyTag = document.body, fbHeadTag = document.head, fbIsTestResponse = 'False', fbEnableInstaMedScript = 'False', fbRenderContainer = document.createElement("div"), fbRenderedCssContainer = document.createElement("div"), fbConfigScript = document.createElement("script"), fbRequireJSScript = document.createElement("script"), fbInstaMedJSScript = document.createElement("script"), fbGeoCaptchaCallback = document.createElement("script"), fbGeoReCaptchaCallback = document.createElement("script"), fbFormulateRenderer = document.createElement("script"), fbRenderedIntegrations = document.createElement("script"), fbRenderedScripts = document.createElement("script"), fbAutoPopulateFromQueryString = document.createElement("script"), fbEmbeddedCss = "", renderedScripts = 'var conditionalSectionJs = function () {\ requirejs([window.formHost + \'/Scripts/require/fbRequire.config.js\'], function (fbRequireConfig) {\ var fbRequire = fbRequireConfig.fbRequire;\ \ fbRequire([\'jquery\', \'he\'], function ($, he) {\ he.encode.options.decimal = true;\ he.encode.options.allowUnsafeSymbols = true;\ \ var sectionConditions = JSON.parse(\'[{"ElementName":"FormField30_d187c175-c567-4374-a612-0908106cdd99","Value":"Other"}]\');\ var conditionOperator = \'and\';\ \ sectionConditions.forEach(function (sectionCondition) {\ $("select[id=" + sectionCondition.ElementName + "]").addClass(\'conditionalSectionListSelection\');\ $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").addClass(\'conditionalSectionListSelection\');\ $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").addClass(\'conditionalSectionListSelection\');\ \ $("select[id=" + sectionCondition.ElementName + "]").on(\'change\', function () {\ checkShowHide();\ });\ \ $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']").on(\'change\', function () {\ checkShowHide();\ });\ \ $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']").on(\'change\', function () {\ checkShowHide();\ });\ });\ \ function checkShowHide() {\ var shouldShowSection = conditionOperator === \'and\'; /* set default to true for AND operation and false for OR operation */\ \ sectionConditions.forEach(function (sectionCondition) {\ checkSelect(sectionCondition); \ checkCheckbox(sectionCondition); \ checkRadio(sectionCondition); \ });\ \ showHideSection(shouldShowSection);\ \ function checkSelect(sectionCondition) {\ var matchingSelect = $("select[id=" + sectionCondition.ElementName + "]")[0];\ \ if (!matchingSelect) {\ return;\ }\ \ if (matchingSelect.type === \'select-multiple\') {\ var hasOneMatchingValue = false;\ \ for (var i = 0; i < matchingSelect.selectedOptions.length; i++) {\ if (encode(matchingSelect.selectedOptions[i].value) === sectionCondition.Value) {\ hasOneMatchingValue = true;\ }\ }\ \ shouldShowSection = mergeCondition(shouldShowSection, hasOneMatchingValue, matchingSelect);\ } else {\ shouldShowSection = mergeCondition(shouldShowSection, encode(matchingSelect.value) === sectionCondition.Value, matchingSelect);\ }\ }\ \ function checkCheckbox(sectionCondition) {\ var matchingCheckboxes = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'checkbox\']");\ \ for (var i = 0; i < matchingCheckboxes.length; i++) {\ if (encode(matchingCheckboxes[i].value) === sectionCondition.Value) {\ shouldShowSection = mergeCondition(shouldShowSection, matchingCheckboxes[i].checked, matchingCheckboxes[i]);\ }\ }\ }\ \ function checkRadio(sectionCondition) {\ var matchingRadios = $("input[id^=\'" + sectionCondition.ElementName + "\'][type=\'radio\']");\ \ for (var i = 0; i < matchingRadios.length; i++) {\ if (encode(matchingRadios[i].value) === sectionCondition.Value) {\ shouldShowSection = mergeCondition(shouldShowSection, matchingRadios[i].checked, matchingRadios[i]);\ }\ }\ }\ }\ \ function mergeCondition(overallResult, newResult, element) {\ newResult = newResult && isParentVisible(element);\ \ if (conditionOperator === \'and\') {\ return overallResult && newResult;\ } else {\ return overallResult || newResult;\ }\ }\ \ function isParentVisible(element) {\ var parentSectionDiv = $(\'#\' + element.id).closest(".fb-section");\ return parentSectionDiv && !parentSectionDiv.is(":hidden");\ }\ \ function encode(myString) {\ myString = he.encode(he.escape(myString));\ \ /* Fixes issues with single quote and backtick encoding */\ var i,\ entities = [\ [\''\', \''\'],\ [\'`\', \'`\']\ ];\ \ for (i = 0; i < entities.length; i++) {\ myString = String(myString).replace(new RegExp(entities[i][0], \'g\'), entities[i][1]);\ }\ \ return myString;\ }\ \ function showHideSection(showSection) {\ if (showSection) {\ $(\'#FormField32_d187c175-c567-4374-a612-0908106cdd99\').show();\ } else {\ $(\'#FormField32_d187c175-c567-4374-a612-0908106cdd99\').hide();\ }\ \ $("#FormField32_d187c175-c567-4374-a612-0908106cdd99 .conditionalSectionListSelection").each(function (i, obj) {\ if (obj.type === \'radio\' || obj.type === \'checkbox\') {\ if (obj.checked) {\ $(\'#\' + obj.id).change();\ }\ } else {\ $(\'#\' + obj.id).change();\ }\ });\ }\ });\ });\ };\ \ fbRequireJSScript.addEventListener("load", conditionalSectionJs);'; if(fbScriptTag.length === 0) { fbScriptTag = document.querySelector("script[src*='d187c175-c567-4374-a612-0908106cdd99']"); } else { fbScriptTag = fbScriptTag[0]; } fbRenderContainer.id = "formRenderContainer"; fbRenderContainer.className = " fbRenderContainer fbRenderContainer_d187c175-c567-4374-a612-0908106cdd99"; fbRenderedCssContainer.id = "fbRenderedCssContainer"; fbConfigScript.type = "text/javascript"; fbRequireJSScript.type = "text/javascript"; fbInstaMedJSScript.type = "text/javascript"; fbGeoCaptchaCallback.type = "text/javascript"; fbGeoReCaptchaCallback.type = "text/javascript"; fbFormulateRenderer.type = "text/javascript"; fbRenderedIntegrations.type = "text/javascript"; fbRenderedScripts.type = "text/javascript"; fbAutoPopulateFromQueryString.type = "text/javascript"; fbRequireJSScript.src = "https://formulate.geonetric.com/Scripts/require.min.js"; fbInstaMedJSScript.src = "https://formulate.geonetric.com/Scripts/vendor/instamed/token.js"; fbInstaMedJSScript.id = "instamed-sdk"; fbGeoCaptchaCallback.src = "https://formulate.geonetric.com/Scripts/geo-captcha-callback.js"; fbGeoReCaptchaCallback.src = "https://www.google.com/recaptcha/api.js?onload=geoFbCaptchaCallback&render=6LdxkTEpAAAAAMKbkhz8-INpQis_mvSaIXnoyC2V"; fbFormulateRenderer.src = "https://formulate.geonetric.com/Scripts/require/formulate-renderer.js?embeddedCssType=0&isTestResponse=False&hasGoogleAnalytics=False"; fbFormulateRenderer.id = "formulateRendererScript"; fbAutoPopulateFromQueryString.src = "https://formulate.geonetric.com/Scripts/auto-populate-from-query-string.js"; if (fbEnableInstaMedScript === 'True') { fbInstaMedJSScript.setAttribute("data-displaymode", "embedded"); fbInstaMedJSScript.setAttribute("data-environment", "UAT"); fbInstaMedJSScript.setAttribute("data-mobiledisplaymode", "embedded"); } fbGeoCaptchaCallback.onload = function() { if(document.querySelectorAll('.geo-fb-recaptcha').length > 0) { fbBodyTag.appendChild(fbGeoReCaptchaCallback); } } fbRequireJSScript.addEventListener("load", function() { fbBodyTag.appendChild(fbFormulateRenderer); fbBodyTag.appendChild(fbAutoPopulateFromQueryString); }); fbFormulateRenderer.addEventListener("load", function () { initFormBuilderForm(); }); var embeddedCssType = 0 switch (embeddedCssType) { case 1: fbEmbeddedCss = ''; break; case 2: fbEmbeddedCss = ''; break; default: fbEmbeddedCss = ''; } if (fbIsTestResponse === 'True') { fbRenderContainer.setAttribute('data-test-mode', 'true'); } else { fbRenderContainer.setAttribute('data-test-mode', 'false'); } fbRenderContainer.innerHTML = "
Required fields are marked with *
\ \ \ \ \ \ \ \ \We care about your financial health, as well. Please provide your insurance information to ensure you are covered. Mercy has financial assistance available if you need it.
WHEN FINISHED FILLING OUT THE ABOVE FORM, CLICK THE “SUBMIT STEP 1” BUTTON BELOW AND THEN PROCEED TO STEP 2 TO SCHEDULE YOUR APPOINTMENT.
\ \ \