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update form.
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@AnalogJ
AnalogJ committed Jul 20, 2024
1 parent f8e876f commit f3510ef
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83 changes: 1 addition & 82 deletions dev/index.html
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Original file line number Diff line number Diff line change
Expand Up @@ -110,70 +110,7 @@ <h1 id="header_53" class="form-header" data-component="header">New Patient Regis
<span class="form-sub-label-container" style="vertical-align:top">
<select name="q56_birthDate[year]" id="input_56_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_56 sublabel_56_year">
<option value="">Please select a year</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
Expand Down Expand Up @@ -233,18 +170,6 @@ <h1 id="header_53" class="form-header" data-component="header">New Patient Regis
<input type="text" id="input_14" name="q14_homePhone" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_14" value="" />
</div>
</li>
<li class="form-line" data-type="control_dropdown" id="id_16">
<label class="form-label form-label-left form-label-auto" id="label_16" for="input_16" aria-hidden="false"> Preferred Method of Contact </label>
<div id="cid_16" class="form-input" data-layout="half">
<select class="form-dropdown" id="input_16" name="q16_preferredMethod" style="width:310px" data-component="dropdown" aria-label="Preferred Method of Contact">
<option value="">Please Select</option>
<option value="Mail">Mail</option>
<option value="Cell Phone">Cell Phone</option>
<option value="Work Phone">Work Phone</option>
<option value="Home Phone">Home Phone</option>
</select>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_17">
<label class="form-label form-label-left form-label-auto" id="label_17" for="input_17" aria-hidden="false"> Driver's License </label>
<div id="cid_17" class="form-input" data-layout="half">
Expand Down Expand Up @@ -290,15 +215,9 @@ <h1 id="header_53" class="form-header" data-component="header">New Patient Regis
<input type="text" id="input_28" name="q28_currentEmployer" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_28" value="" />
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_30">
<label class="form-label form-label-left form-label-auto" id="label_30" for="input_30" aria-hidden="false"> Primary Care Provider </label>
<div id="cid_30" class="form-input" data-layout="half">
<input type="text" id="input_30" name="q30_primaryCare" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_30" value="" />
</div>
</li>

<li class="form-line" data-type="control_textbox" id="id_31">
<label class="form-label form-label-left form-label-auto" id="label_31" for="input_30" aria-hidden="false"> Attach Medical Records</label>
<label class="form-label form-label-left form-label-auto" id="label_31" aria-hidden="false"> Attach Medical Records</label>
<fasten-stitch public-id="public_test_rei2un7aagh5pquwikxh2dsyq23bsdyu4l8vm9eq29ftu" external-id="user-opaque-id-1231241"></fasten-stitch>
</li>
<li class="form-line" data-type="control_button" id="id_52">
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75 changes: 1 addition & 74 deletions prod/index.html
View file
Original file line number Diff line number Diff line change
Expand Up @@ -110,61 +110,6 @@ <h1 id="header_53" class="form-header" data-component="header">New Patient Regis
<span class="form-sub-label-container" style="vertical-align:top">
<select name="q56_birthDate[year]" id="input_56_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_56 sublabel_56_year">
<option value="">Please select a year</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
Expand Down Expand Up @@ -233,18 +178,6 @@ <h1 id="header_53" class="form-header" data-component="header">New Patient Regis
<input type="text" id="input_14" name="q14_homePhone" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_14" value="" />
</div>
</li>
<li class="form-line" data-type="control_dropdown" id="id_16">
<label class="form-label form-label-left form-label-auto" id="label_16" for="input_16" aria-hidden="false"> Preferred Method of Contact </label>
<div id="cid_16" class="form-input" data-layout="half">
<select class="form-dropdown" id="input_16" name="q16_preferredMethod" style="width:310px" data-component="dropdown" aria-label="Preferred Method of Contact">
<option value="">Please Select</option>
<option value="Mail">Mail</option>
<option value="Cell Phone">Cell Phone</option>
<option value="Work Phone">Work Phone</option>
<option value="Home Phone">Home Phone</option>
</select>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_17">
<label class="form-label form-label-left form-label-auto" id="label_17" for="input_17" aria-hidden="false"> Driver's License </label>
<div id="cid_17" class="form-input" data-layout="half">
Expand Down Expand Up @@ -290,15 +223,9 @@ <h1 id="header_53" class="form-header" data-component="header">New Patient Regis
<input type="text" id="input_28" name="q28_currentEmployer" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_28" value="" />
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_30">
<label class="form-label form-label-left form-label-auto" id="label_30" for="input_30" aria-hidden="false"> Primary Care Provider </label>
<div id="cid_30" class="form-input" data-layout="half">
<input type="text" id="input_30" name="q30_primaryCare" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" data-component="textbox" aria-labelledby="label_30" value="" />
</div>
</li>

<li class="form-line" data-type="control_textbox" id="id_31">
<label class="form-label form-label-left form-label-auto" id="label_31" for="input_30" aria-hidden="false"> Attach Medical Records</label>
<label class="form-label form-label-left form-label-auto" id="label_31" aria-hidden="false"> Attach Medical Records</label>
<fasten-stitch public-id="public_test_6f5j7qj54rlyajv6u8r36z0iu5v9qjf87f77tzl3k6ezu" external-id="user-opaque-id-8923472"></fasten-stitch>
</li>
<li class="form-line" data-type="control_button" id="id_52">
Expand Down

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