REQUEST A TRIAL

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margin-top:20px !important; margin-left:0 !important; }<!– [et_pb_line_break_holder] –> }<!– [et_pb_line_break_holder] –></style><!– [et_pb_line_break_holder] –><form method="POST" action="https://resqmedical.activehosted.com/proc.php" id="_form_9_" class="_form _form_9 _inline-form _dark" novalidate><!– [et_pb_line_break_holder] –> <input type="hidden" name="u" value="9" /><!– [et_pb_line_break_holder] –> <input type="hidden" name="f" value="9" /><!– [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 _x72874349 _full_width _clear" ><!– [et_pb_line_break_holder] –> <div class="_form-title"><!– [et_pb_line_break_holder] –> Request A Trial<!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _x75697205 _full_width _clear" ><!– [et_pb_line_break_holder] –> <div class="_html-code"><!– [et_pb_line_break_holder] –> <p><!– [et_pb_line_break_holder] –> Complete the form and a ResQ Medical representative will contact you to discuss a free limited trial for your Program or Institution.<!– [et_pb_line_break_holder] –> </p><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _field1 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> Title<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> <div class="_field-wrapper"><!– [et_pb_line_break_holder] –> <input type="text" name="field[1]" value="" placeholder="" /><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _x36801659 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> First 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="firstname" placeholder="Type your first name" required/><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _x21890154 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> Last 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="lastname" placeholder="Type your last name" required/><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _field2 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> Suffix<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> <div class="_field-wrapper"><!– [et_pb_line_break_holder] –> <input type="text" name="field[2]" value="" placeholder="" /><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _x97631748 _full_width " ><!– [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="Type your email" required/><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _x43973666 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> Phone<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> <div class="_field-wrapper"><!– [et_pb_line_break_holder] –> <input type="text" name="phone" placeholder="Type your phone number" /><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _field3 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> Hospital 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="field[3]" value="" placeholder="" /><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _field4 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> Job Title<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4CEO/CMO/CTO" type="radio" name="field[4]" value="CEO/CMO/CTO" ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4CEO/CMO/CTO"><!– [et_pb_line_break_holder] –> CEO/CMO/CTO<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4DIO" type="radio" name="field[4]" value="DIO" ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4DIO"><!– [et_pb_line_break_holder] –> DIO<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4Program Director" type="radio" name="field[4]" value="Program Director" ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4Program Director"><!– [et_pb_line_break_holder] –> Program Director<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4Program Coordinator" type="radio" name="field[4]" value="Program Coordinator" ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4Program Coordinator"><!– [et_pb_line_break_holder] –> Program Coordinator<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4GME Staff" type="radio" name="field[4]" value="GME Staff" ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4GME Staff"><!– [et_pb_line_break_holder] –> GME Staff<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4Resident" type="radio" name="field[4]" value="Resident" ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4Resident"><!– [et_pb_line_break_holder] –> Resident<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_row"><!– [et_pb_line_break_holder] –> <input id="field_4Other" type="radio" name="field[4]" value="Other" checked ><!– [et_pb_line_break_holder] –> <span><!– [et_pb_line_break_holder] –> <label for="field_4Other"><!– [et_pb_line_break_holder] –> Other<!– [et_pb_line_break_holder] –> </span><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_form_element _field5 _full_width " ><!– [et_pb_line_break_holder] –> <label class="_form-label"><!– [et_pb_line_break_holder] –> If "Other" please enter your job title.<!– [et_pb_line_break_holder] –> </label><!– [et_pb_line_break_holder] –> <div class="_field-wrapper"><!– [et_pb_line_break_holder] –> <input type="text" name="field[5]" value="" placeholder="" /><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> </div><!– [et_pb_line_break_holder] –> <div class="_button-wrapper _full_width"><!– [et_pb_line_break_holder] –> <button id="_form_9_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><script type="text/javascript"><!– [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] –> 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_9_');<!– [et_pb_line_break_holder] –> var allInputs = form_to_submit.querySelectorAll('input, select, textarea'), tooltips = [], submitted = false;<!– [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] –> 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] –> 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] –> 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, '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(input, 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] –> 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] –> var serialized = _form_serialize(document.getElementById('_form_9_'));<!– [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('https://resqmedical.activehosted.com/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>

<script type="text/javascript"><!– [et_pb_line_break_holder] –> var trackcmp_email = ";<!– [et_pb_line_break_holder] –> var trackcmp = document.createElement("script");<!– [et_pb_line_break_holder] –> trackcmp.async = true;<!– [et_pb_line_break_holder] –> trackcmp.type = 'text/javascript';<!– [et_pb_line_break_holder] –> trackcmp.src = '//trackcmp.net/visit?actid=89186684&e='+encodeURIComponent(trackcmp_email)+'&r='+encodeURIComponent(document.referrer)+'&u='+encodeURIComponent(window.location.href);<!– [et_pb_line_break_holder] –> var trackcmp_s = document.getElementsByTagName("script");<!– [et_pb_line_break_holder] –> if (trackcmp_s.length) {<!– [et_pb_line_break_holder] –> trackcmp_s[0].parentNode.appendChild(trackcmp);<!– [et_pb_line_break_holder] –> } else {<!– [et_pb_line_break_holder] –> var trackcmp_h = document.getElementsByTagName("head");<!– [et_pb_line_break_holder] –> trackcmp_h.length && trackcmp_h[0].appendChild(trackcmp);<!– [et_pb_line_break_holder] –> }<!– [et_pb_line_break_holder] –></script>