<style><!-- [et_pb_line_break_holder] --> #_form_1_ { font-size:14px; line-height:1.6; font-family:arial, helvetica, sans-serif; margin:0; }<!-- [et_pb_line_break_holder] --> #_form_1_ * { outline:0; }<!-- [et_pb_line_break_holder] --> ._form_hide { display:none; visibility:hidden; }<!-- [et_pb_line_break_holder] --> ._form_show { display:block; visibility:visible; }<!-- [et_pb_line_break_holder] --> #_form_1_._form-top { top:0; }<!-- [et_pb_line_break_holder] --> #_form_1_._form-bottom { bottom:0; }<!-- [et_pb_line_break_holder] --> #_form_1_._form-left { left:0; }<!-- [et_pb_line_break_holder] --> #_form_1_._form-right { right:0; }<!-- [et_pb_line_break_holder] --> #_form_1_ input[type="text"],#_form_1_ input[type="date"],#_form_1_ textarea { padding:6px; height:auto; border:#979797 1px solid; border-radius:4px; color:#000 !important; font-size:13px; -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; }<!-- [et_pb_line_break_holder] --> #_form_1_ textarea { resize:none; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._submit { -webkit-appearance:none; cursor:pointer; font-family:arial, sans-serif; font-size:14px; text-align:center; background:#ed7607 !important; border:0 !important; color:#fffefc !important; padding:10px !important; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._close-icon { cursor:pointer; background-image:url('https://d226aj4ao1t61q.cloudfront.net/esfkyjh1u_forms-close-dark.png'); background-repeat:no-repeat; background-size:14.2px 14.2px; position:absolute; display:block; top:11px; right:9px; overflow:hidden; width:16.2px; height:16.2px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._close-icon:before { position:relative; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-body { margin-bottom:30px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-image-left { width:150px; float:left; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-content-right { margin-left:164px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-branding { color:#fff; font-size:10px; clear:both; text-align:left; margin-top:30px; font-weight:100; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-branding ._logo { display:block; width:130px; height:14px; margin-top:6px; background-image:url('https://d226aj4ao1t61q.cloudfront.net/hh9ujqgv5_aclogo_li.png'); background-size:130px auto; background-repeat:no-repeat; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-label,#_form_1_ ._form_element ._form-label { font-weight:bold; margin-bottom:5px; display:block; }<!-- [et_pb_line_break_holder] --> #_form_1_._dark ._form-branding { color:#333; }<!-- [et_pb_line_break_holder] --> #_form_1_._dark ._form-branding ._logo { background-image:url('https://d226aj4ao1t61q.cloudfront.net/jftq2c8s_aclogo_dk.png'); }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element { position:relative; margin-bottom:10px; font-size:0; max-width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element * { font-size:14px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element._clear { clear:both; width:100%; float:none; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element._clear:after { clear:left; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element input[type="text"],#_form_1_ ._form_element input[type="date"],#_form_1_ ._form_element select,#_form_1_ ._form_element textarea:not(.g-recaptcha-response) { display:block; width:100%; -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._field-wrapper { position:relative; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._inline-style { float:left; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._inline-style input[type="text"] { width:150px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._inline-style:not(._clear) + ._inline-style:not(._clear) { margin-left:20px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element img._form-image { max-width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._clear-element { clear:left; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._full_width { width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_full_field { display:block; width:100%; margin-bottom:10px; }<!-- [et_pb_line_break_holder] --> #_form_1_ input[type="text"]._has_error,#_form_1_ textarea._has_error { border:#f37c7b 1px solid; }<!-- [et_pb_line_break_holder] --> #_form_1_ input[type="checkbox"]._has_error { outline:#f37c7b 1px solid; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error { display:block; position:absolute; font-size:13px; z-index:10000001; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error._above { padding-bottom:4px; top:-41px; right:0; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error._below { padding-top:4px; top:100%; right:0; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error._above ._error-arrow { bottom:0; right:15px; border-left:5px solid transparent; border-right:5px solid transparent; border-top:5px solid #f37c7b; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error._below ._error-arrow { top:0; right:15px; border-left:5px solid transparent; border-right:5px solid transparent; border-bottom:5px solid #f37c7b; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error-inner { padding:8px 12px; background-color:#f37c7b; font-size:13px; font-family:arial, sans-serif; color:#fff; text-align:center; text-decoration:none; -webkit-border-radius:4px; -moz-border-radius:4px; border-radius:4px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error-inner._form_error { margin-bottom:5px; text-align:left; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._button-wrapper ._error-inner._form_error { position:static; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error-inner._no_arrow { margin-bottom:10px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error-arrow { position:absolute; width:0; height:0; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._error-html { margin-bottom:10px; }<!-- [et_pb_line_break_holder] --> .pika-single { z-index:10000001 !important; }<!-- [et_pb_line_break_holder] --> @media all and (min-width:320px) and (max-width:667px) { ::-webkit-scrollbar { display:none; }<!-- [et_pb_line_break_holder] --> #_form_1_ { margin:0; width:100%; min-width:100%; max-width:100%; box-sizing:border-box; }<!-- [et_pb_line_break_holder] --> #_form_1_ * { -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; font-size:1em; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-content { margin:0; width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-inner { display:block; min-width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-title,#_form_1_ ._inline-style { margin-top:0; margin-right:0; margin-left:0; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-title { font-size:1.2em; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form_element { margin:0 0 20px; padding:0; width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-element,#_form_1_ ._inline-style,#_form_1_ input[type="text"],#_form_1_ label,#_form_1_ p,#_form_1_ textarea:not(.g-recaptcha-response) { float:none; display:block; width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._row._checkbox-radio label { display:inline; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._row,#_form_1_ p,#_form_1_ label { margin-bottom:0.7em; width:100%; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._row input[type="checkbox"],#_form_1_ ._row input[type="radio"] { margin:0 !important; vertical-align:middle !important; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._row input[type="checkbox"] + span label { display:inline; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._row span label { margin:0 !important; width:initial !important; vertical-align:middle !important; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-image { max-width:100%; height:auto !important; }<!-- [et_pb_line_break_holder] --> #_form_1_ input[type="text"] { padding-left:10px; padding-right:10px; font-size:16px; line-height:1.3em; -webkit-appearance:none; }<!-- [et_pb_line_break_holder] --> #_form_1_ input[type="radio"],#_form_1_ input[type="checkbox"] { display:inline-block; width:1.3em; height:1.3em; font-size:1em; margin:0 0.3em 0 0; vertical-align:baseline; }<!-- [et_pb_line_break_holder] --> #_form_1_ button[type="submit"] { padding:20px; font-size:1.5em; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._inline-style { margin:20px 0 0 !important; }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> #_form_1_ { position:relative; text-align:left; margin:25px auto 0; padding:20px; -webkit-box-sizing:border-box; -moz-box-sizing:border-box; box-sizing:border-box; *zoom:1; background:transparent !important; border:0px solid #b0b0b0 !important; -moz-border-radius:0px !important; -webkit-border-radius:0px !important; border-radius:0px !important; color:#fa760a !important; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-title { font-size:22px; line-height:22px; font-weight:600; margin-bottom:0; }<!-- [et_pb_line_break_holder] --> #_form_1_:before,#_form_1_:after { content:" "; display:table; }<!-- [et_pb_line_break_holder] --> #_form_1_:after { clear:both; }<!-- [et_pb_line_break_holder] --> #_form_1_._inline-style { width:auto; display:inline-block; }<!-- [et_pb_line_break_holder] --> #_form_1_._inline-style input[type="text"],#_form_1_._inline-style input[type="date"] { padding:10px 12px; }<!-- [et_pb_line_break_holder] --> #_form_1_._inline-style button._inline-style { position:relative; top:27px; }<!-- [et_pb_line_break_holder] --> #_form_1_._inline-style p { margin:0; }<!-- [et_pb_line_break_holder] --> #_form_1_._inline-style ._button-wrapper { position:relative; margin:27px 12.5px 0 20px; }<!-- [et_pb_line_break_holder] --> #_form_1_ ._form-thank-you { position:relative; left:0; right:0; text-align:center; font-size:18px; }<!-- [et_pb_line_break_holder] --> @media all and (min-width:320px) and (max-width:667px) { #_form_1_._inline-form._inline-style ._inline-style._button-wrapper { margin-top:20px !important; margin-left:0 !important; }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --></style><!-- [et_pb_line_break_holder] --><div style="text-align: center;"><!-- [et_pb_line_break_holder] --> <form method="POST" action="http://ventinovamedicalbv.mark-i.nl/proc.php" id="_form_1_" class="_form _form_1 _inline-form _inline-style _dark" novalidate><!-- [et_pb_line_break_holder] --> <input type="hidden" name="u" value="1" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="f" value="1" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="s" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="c" value="0" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="m" value="0" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="act" value="sub" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="v" value="2" /><!-- [et_pb_line_break_holder] --> <div class="_form-content"><!-- [et_pb_line_break_holder] --> <div class="_form_element _x23417150 _inline-style " ><!-- [et_pb_line_break_holder] --> <label class="_form-label"><!-- [et_pb_line_break_holder] --> Full Name<!-- [et_pb_line_break_holder] --> </label><!-- [et_pb_line_break_holder] --> <div class="_field-wrapper"><!-- [et_pb_line_break_holder] --> <input type="text" name="fullname" placeholder="" /><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="_form_element _x97965741 _inline-style " ><!-- [et_pb_line_break_holder] --> <label class="_form-label"><!-- [et_pb_line_break_holder] --> Email*<!-- [et_pb_line_break_holder] --> </label><!-- [et_pb_line_break_holder] --> <div class="_field-wrapper"><!-- [et_pb_line_break_holder] --> <input type="text" name="email" placeholder="" required/><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="_button-wrapper _inline-style"><!-- [et_pb_line_break_holder] --> <button id="_form_1_submit" class="_submit" type="submit"><!-- [et_pb_line_break_holder] --> Submit<!-- [et_pb_line_break_holder] --> </button><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="_clear-element"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <div class="_form-thank-you" style="display:none;"><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --></div><script type="text/javascript"><!-- [et_pb_line_break_holder] -->window.cfields = [];<!-- [et_pb_line_break_holder] -->window._show_thank_you = function(id, message, trackcmp_url) {<!-- [et_pb_line_break_holder] --> var form = document.getElementById('_form_' + id + '_'), thank_you = form.querySelector('._form-thank-you');<!-- [et_pb_line_break_holder] --> form.querySelector('._form-content').style.display = 'none';<!-- [et_pb_line_break_holder] --> thank_you.innerHTML = message;<!-- [et_pb_line_break_holder] --> thank_you.style.display = 'block';<!-- [et_pb_line_break_holder] --> if (typeof(trackcmp_url) != 'undefined' && trackcmp_url) {<!-- [et_pb_line_break_holder] --> // Site tracking URL to use after inline form submission.<!-- [et_pb_line_break_holder] --> _load_script(trackcmp_url);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (typeof window._form_callback !== 'undefined') window._form_callback(id);<!-- [et_pb_line_break_holder] -->};<!-- [et_pb_line_break_holder] -->window._show_error = function(id, message, html) {<!-- [et_pb_line_break_holder] --> var form = document.getElementById('_form_' + id + '_'), err = document.createElement('div'), button = form.querySelector('button'), old_error = form.querySelector('._form_error');<!-- [et_pb_line_break_holder] --> if (old_error) old_error.parentNode.removeChild(old_error);<!-- [et_pb_line_break_holder] --> err.innerHTML = message;<!-- [et_pb_line_break_holder] --> err.className = '_error-inner _form_error _no_arrow';<!-- [et_pb_line_break_holder] --> var wrapper = document.createElement('div');<!-- [et_pb_line_break_holder] --> wrapper.className = '_form-inner';<!-- [et_pb_line_break_holder] --> wrapper.appendChild(err);<!-- [et_pb_line_break_holder] --> button.parentNode.insertBefore(wrapper, button);<!-- [et_pb_line_break_holder] --> document.querySelector('[id^="_form"][id$="_submit"]').disabled = false;<!-- [et_pb_line_break_holder] --> if (html) {<!-- [et_pb_line_break_holder] --> var div = document.createElement('div');<!-- [et_pb_line_break_holder] --> div.className = '_error-html';<!-- [et_pb_line_break_holder] --> div.innerHTML = html;<!-- [et_pb_line_break_holder] --> err.appendChild(div);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] -->};<!-- [et_pb_line_break_holder] -->window._load_script = function(url, callback) {<!-- [et_pb_line_break_holder] --> var head = document.querySelector('head'), script = document.createElement('script'), r = false;<!-- [et_pb_line_break_holder] --> script.type = 'text/javascript';<!-- [et_pb_line_break_holder] --> script.charset = 'utf-8';<!-- [et_pb_line_break_holder] --> script.src = url;<!-- [et_pb_line_break_holder] --> if (callback) {<!-- [et_pb_line_break_holder] --> script.onload = script.onreadystatechange = function() {<!-- [et_pb_line_break_holder] --> if (!r && (!this.readyState || this.readyState == 'complete')) {<!-- [et_pb_line_break_holder] --> r = true;<!-- [et_pb_line_break_holder] --> callback();<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> head.appendChild(script);<!-- [et_pb_line_break_holder] -->};<!-- [et_pb_line_break_holder] -->(function() {<!-- [et_pb_line_break_holder] --> if (window.location.search.search("excludeform") !== -1) return false;<!-- [et_pb_line_break_holder] --> var getCookie = function(name) {<!-- [et_pb_line_break_holder] --> var match = document.cookie.match(new RegExp('(^|; )' + name + '=([^;]+)'));<!-- [et_pb_line_break_holder] --> return match ? match[2] : null;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> var setCookie = function(name, value) {<!-- [et_pb_line_break_holder] --> var now = new Date();<!-- [et_pb_line_break_holder] --> var time = now.getTime();<!-- [et_pb_line_break_holder] --> var expireTime = time + 1000 * 60 * 60 * 24 * 365;<!-- [et_pb_line_break_holder] --> now.setTime(expireTime);<!-- [et_pb_line_break_holder] --> document.cookie = name + '=' + value + '; expires=' + now + ';path=/';<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> var addEvent = function(element, event, func) {<!-- [et_pb_line_break_holder] --> if (element.addEventListener) {<!-- [et_pb_line_break_holder] --> element.addEventListener(event, func);<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> var oldFunc = element['on' + event];<!-- [et_pb_line_break_holder] --> element['on' + event] = function() {<!-- [et_pb_line_break_holder] --> oldFunc.apply(this, arguments);<!-- [et_pb_line_break_holder] --> func.apply(this, arguments);<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> var _removed = false;<!-- [et_pb_line_break_holder] --> var form_to_submit = document.getElementById('_form_1_');<!-- [et_pb_line_break_holder] --> var allInputs = form_to_submit.querySelectorAll('input, select, textarea'), tooltips = [], submitted = false;<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> var getUrlParam = function(name) {<!-- [et_pb_line_break_holder] --> var regexStr = '[\?&]' + name + '=([^&#]*)';<!-- [et_pb_line_break_holder] --> var results = new RegExp(regexStr, 'i').exec(window.location.href);<!-- [et_pb_line_break_holder] --> return results != undefined ? decodeURIComponent(results[1]) : false;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> for (var i = 0; i < allInputs.length; i++) {<!-- [et_pb_line_break_holder] --> var regexStr = "field\\[(\\d+)\\]";<!-- [et_pb_line_break_holder] --> var results = new RegExp(regexStr).exec(allInputs[i].name);<!-- [et_pb_line_break_holder] --> if (results != undefined) {<!-- [et_pb_line_break_holder] --> allInputs[i].dataset.name = window.cfields[results[1]];<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> allInputs[i].dataset.name = allInputs[i].name;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> var fieldVal = getUrlParam(allInputs[i].dataset.name);<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> if (fieldVal) {<!-- [et_pb_line_break_holder] --> if (allInputs[i].type == "radio" || allInputs[i].type == "checkbox") {<!-- [et_pb_line_break_holder] --> if (allInputs[i].value == fieldVal) {<!-- [et_pb_line_break_holder] --> allInputs[i].checked = true;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> allInputs[i].value = fieldVal;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --> var remove_tooltips = function() {<!-- [et_pb_line_break_holder] --> for (var i = 0; i < tooltips.length; i++) {<!-- [et_pb_line_break_holder] --> tooltips[i].tip.parentNode.removeChild(tooltips[i].tip);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> tooltips = [];<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var remove_tooltip = function(elem) {<!-- [et_pb_line_break_holder] --> for (var i = 0; i < tooltips.length; i++) {<!-- [et_pb_line_break_holder] --> if (tooltips[i].elem === elem) {<!-- [et_pb_line_break_holder] --> tooltips[i].tip.parentNode.removeChild(tooltips[i].tip);<!-- [et_pb_line_break_holder] --> tooltips.splice(i, 1);<!-- [et_pb_line_break_holder] --> return;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var create_tooltip = function(elem, text) {<!-- [et_pb_line_break_holder] --> var tooltip = document.createElement('div'), arrow = document.createElement('div'), inner = document.createElement('div'), new_tooltip = {};<!-- [et_pb_line_break_holder] --> if (elem.type != 'radio' && elem.type != 'checkbox') {<!-- [et_pb_line_break_holder] --> tooltip.className = '_error';<!-- [et_pb_line_break_holder] --> arrow.className = '_error-arrow';<!-- [et_pb_line_break_holder] --> inner.className = '_error-inner';<!-- [et_pb_line_break_holder] --> inner.innerHTML = text;<!-- [et_pb_line_break_holder] --> tooltip.appendChild(arrow);<!-- [et_pb_line_break_holder] --> tooltip.appendChild(inner);<!-- [et_pb_line_break_holder] --> elem.parentNode.appendChild(tooltip);<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> tooltip.className = '_error-inner _no_arrow';<!-- [et_pb_line_break_holder] --> tooltip.innerHTML = text;<!-- [et_pb_line_break_holder] --> elem.parentNode.insertBefore(tooltip, elem);<!-- [et_pb_line_break_holder] --> new_tooltip.no_arrow = true;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> new_tooltip.tip = tooltip;<!-- [et_pb_line_break_holder] --> new_tooltip.elem = elem;<!-- [et_pb_line_break_holder] --> tooltips.push(new_tooltip);<!-- [et_pb_line_break_holder] --> return new_tooltip;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var resize_tooltip = function(tooltip) {<!-- [et_pb_line_break_holder] --> var rect = tooltip.elem.getBoundingClientRect();<!-- [et_pb_line_break_holder] --> var doc = document.documentElement, scrollPosition = rect.top - ((window.pageYOffset || doc.scrollTop) - (doc.clientTop || 0));<!-- [et_pb_line_break_holder] --> if (scrollPosition < 40) {<!-- [et_pb_line_break_holder] --> tooltip.tip.className = tooltip.tip.className.replace(/ ?(_above|_below) ?/g, '') + ' _below';<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> tooltip.tip.className = tooltip.tip.className.replace(/ ?(_above|_below) ?/g, '') + ' _above';<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var resize_tooltips = function() {<!-- [et_pb_line_break_holder] --> if (_removed) return;<!-- [et_pb_line_break_holder] --> for (var i = 0; i < tooltips.length; i++) {<!-- [et_pb_line_break_holder] --> if (!tooltips[i].no_arrow) resize_tooltip(tooltips[i]);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var validate_field = function(elem, remove) {<!-- [et_pb_line_break_holder] --> var tooltip = null, value = elem.value, no_error = true;<!-- [et_pb_line_break_holder] --> remove ? remove_tooltip(elem) : false;<!-- [et_pb_line_break_holder] --> if (elem.type != 'checkbox') elem.className = elem.className.replace(/ ?_has_error ?/g, '');<!-- [et_pb_line_break_holder] --> if (elem.getAttribute('required') !== null) {<!-- [et_pb_line_break_holder] --> if (elem.type == 'radio' || (elem.type == 'checkbox' && /any/.test(elem.className))) {<!-- [et_pb_line_break_holder] --> var elems = form_to_submit.elements[elem.name];<!-- [et_pb_line_break_holder] --> if (!(elems instanceof NodeList || elems instanceof HTMLCollection) || elems.length <= 1) {<!-- [et_pb_line_break_holder] --> no_error = elem.checked;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> else {<!-- [et_pb_line_break_holder] --> no_error = false;<!-- [et_pb_line_break_holder] --> for (var i = 0; i < elems.length; i++) {<!-- [et_pb_line_break_holder] --> if (elems[i].checked) no_error = true;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (!no_error) {<!-- [et_pb_line_break_holder] --> tooltip = create_tooltip(elem, "Please select an option.");<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> } else if (elem.type =='checkbox') {<!-- [et_pb_line_break_holder] --> var elems = form_to_submit.elements[elem.name], found = false, err = [];<!-- [et_pb_line_break_holder] --> no_error = true;<!-- [et_pb_line_break_holder] --> for (var i = 0; i < elems.length; i++) {<!-- [et_pb_line_break_holder] --> if (elems[i].getAttribute('required') === null) continue;<!-- [et_pb_line_break_holder] --> if (!found && elems[i] !== elem) return true;<!-- [et_pb_line_break_holder] --> found = true;<!-- [et_pb_line_break_holder] --> elems[i].className = elems[i].className.replace(/ ?_has_error ?/g, '');<!-- [et_pb_line_break_holder] --> if (!elems[i].checked) {<!-- [et_pb_line_break_holder] --> no_error = false;<!-- [et_pb_line_break_holder] --> elems[i].className = elems[i].className + ' _has_error';<!-- [et_pb_line_break_holder] --> err.push("Checking %s is required".replace("%s", elems[i].value));<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (!no_error) {<!-- [et_pb_line_break_holder] --> tooltip = create_tooltip(elem, err.join('<br/>'));<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> } else if (elem.tagName == 'SELECT') {<!-- [et_pb_line_break_holder] --> var selected = true;<!-- [et_pb_line_break_holder] --> if (elem.multiple) {<!-- [et_pb_line_break_holder] --> selected = false;<!-- [et_pb_line_break_holder] --> for (var i = 0; i < elem.options.length; i++) {<!-- [et_pb_line_break_holder] --> if (elem.options[i].selected) {<!-- [et_pb_line_break_holder] --> selected = true;<!-- [et_pb_line_break_holder] --> break;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> } else {<!-- [et_pb_line_break_holder] --> for (var i = 0; i < elem.options.length; i++) {<!-- [et_pb_line_break_holder] --> if (elem.options[i].selected && !elem.options[i].value) {<!-- [et_pb_line_break_holder] --> selected = false;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (!selected) {<!-- [et_pb_line_break_holder] --> elem.className = elem.className + ' _has_error';<!-- [et_pb_line_break_holder] --> no_error = false;<!-- [et_pb_line_break_holder] --> tooltip = create_tooltip(elem, "Please select an option.");<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> } else if (value === undefined || value === null || value === '') {<!-- [et_pb_line_break_holder] --> elem.className = elem.className + ' _has_error';<!-- [et_pb_line_break_holder] --> no_error = false;<!-- [et_pb_line_break_holder] --> tooltip = create_tooltip(elem, "This field is required.");<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (no_error && elem.name == 'email') {<!-- [et_pb_line_break_holder] --> if (!value.match(/^[\+_a-z0-9-'&=]+(\.[\+_a-z0-9-']+)*@[a-z0-9-]+(\.[a-z0-9-]+)*(\.[a-z]{2,})$/i)) {<!-- [et_pb_line_break_holder] --> elem.className = elem.className + ' _has_error';<!-- [et_pb_line_break_holder] --> no_error = false;<!-- [et_pb_line_break_holder] --> tooltip = create_tooltip(elem, "Enter a valid email address.");<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (no_error && /date_field/.test(elem.className)) {<!-- [et_pb_line_break_holder] --> if (!value.match(/^\d\d\d\d-\d\d-\d\d$/)) {<!-- [et_pb_line_break_holder] --> elem.className = elem.className + ' _has_error';<!-- [et_pb_line_break_holder] --> no_error = false;<!-- [et_pb_line_break_holder] --> tooltip = create_tooltip(elem, "Enter a valid date.");<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> tooltip ? resize_tooltip(tooltip) : false;<!-- [et_pb_line_break_holder] --> return no_error;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var needs_validate = function(el) {<!-- [et_pb_line_break_holder] --> return el.name == 'email' || el.getAttribute('required') !== null;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> var validate_form = function(e) {<!-- [et_pb_line_break_holder] --> var err = form_to_submit.querySelector('._form_error'), no_error = true;<!-- [et_pb_line_break_holder] --> if (!submitted) {<!-- [et_pb_line_break_holder] --> submitted = true;<!-- [et_pb_line_break_holder] --> for (var i = 0, len = allInputs.length; i < len; i++) {<!-- [et_pb_line_break_holder] --> var input = allInputs[i];<!-- [et_pb_line_break_holder] --> if (needs_validate(input)) {<!-- [et_pb_line_break_holder] --> if (input.type == 'text') {<!-- [et_pb_line_break_holder] --> addEvent(input, 'blur', function() {<!-- [et_pb_line_break_holder] --> this.value = this.value.trim();<!-- [et_pb_line_break_holder] --> validate_field(this, true);<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> addEvent(input, 'input', function() {<!-- [et_pb_line_break_holder] --> validate_field(this, true);<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> } else if (input.type == 'radio' || input.type == 'checkbox') {<!-- [et_pb_line_break_holder] --> (function(el) {<!-- [et_pb_line_break_holder] --> var radios = form_to_submit.elements[el.name];<!-- [et_pb_line_break_holder] --> for (var i = 0; i < radios.length; i++) {<!-- [et_pb_line_break_holder] --> addEvent(radios[i], 'click', function() {<!-- [et_pb_line_break_holder] --> validate_field(el, true);<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> })(input);<!-- [et_pb_line_break_holder] --> } else if (input.tagName == 'SELECT') {<!-- [et_pb_line_break_holder] --> addEvent(input, 'change', function() {<!-- [et_pb_line_break_holder] --> validate_field(this, true);<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> remove_tooltips();<!-- [et_pb_line_break_holder] --> for (var i = 0, len = allInputs.length; i < len; i++) {<!-- [et_pb_line_break_holder] --> var elem = allInputs[i];<!-- [et_pb_line_break_holder] --> if (needs_validate(elem)) {<!-- [et_pb_line_break_holder] --> if (elem.tagName.toLowerCase() !== "select") {<!-- [et_pb_line_break_holder] --> elem.value = elem.value.trim();<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> validate_field(elem) ? true : no_error = false;<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> if (!no_error && e) {<!-- [et_pb_line_break_holder] --> e.preventDefault();<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> resize_tooltips();<!-- [et_pb_line_break_holder] --> return no_error;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> addEvent(window, 'resize', resize_tooltips);<!-- [et_pb_line_break_holder] --> addEvent(window, 'scroll', resize_tooltips);<!-- [et_pb_line_break_holder] --> window._old_serialize = null;<!-- [et_pb_line_break_holder] --> if (typeof serialize !== 'undefined') window._old_serialize = window.serialize;<!-- [et_pb_line_break_holder] --> _load_script("//d3rxaij56vjege.cloudfront.net/form-serialize/0.3/serialize.min.js", function() {<!-- [et_pb_line_break_holder] --> window._form_serialize = window.serialize;<!-- [et_pb_line_break_holder] --> if (window._old_serialize) window.serialize = window._old_serialize;<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> var form_submit = function(e) {<!-- [et_pb_line_break_holder] --> e.preventDefault();<!-- [et_pb_line_break_holder] --> if (validate_form()) {<!-- [et_pb_line_break_holder] --> // use this trick to get the submit button & disable it using plain javascript<!-- [et_pb_line_break_holder] --> document.querySelector('[id^="_form"][id$="_submit"]').disabled = true;<!-- [et_pb_line_break_holder] --> var serialized = _form_serialize(document.getElementById('_form_1_'));<!-- [et_pb_line_break_holder] --> var err = form_to_submit.querySelector('._form_error');<!-- [et_pb_line_break_holder] --> err ? err.parentNode.removeChild(err) : false;<!-- [et_pb_line_break_holder] --> _load_script('http://ventinovamedicalbv.mark-i.nl/proc.php?' + serialized + '&jsonp=true');<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> return false;<!-- [et_pb_line_break_holder] --> };<!-- [et_pb_line_break_holder] --> addEvent(form_to_submit, 'submit', form_submit);<!-- [et_pb_line_break_holder] -->})();<!-- [et_pb_line_break_holder] --><!-- [et_pb_line_break_holder] --></script>