<?php
require_once('config.php');
$pms = $_REQUEST['pms'];
$methodid=$_REQUEST['mid'];
$pharmacyname = $_REQUEST['pharmacyname'];
?>

<?php
if($pms=='winrx'){?>

    <!-- Bootstrap CSS -->
    <link href="css/bootstrap.min.css" rel="stylesheet">
    <link href="css/font-awesome.min.css" rel="stylesheet">
    <link rel="stylesheet" type="text/css" href="css/util.css">
    <link rel="stylesheet" type="text/css" href="css/main.css">
    <link href="css/w3.css" type="text/css" rel="stylesheet" />
    <script src="js/the-datepicker.min.js"></script>
    <link rel="stylesheet" href="css/the-datepicker.css">
    <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.1/jquery.min.js"></script>
    <script>

        $( document ).ready(function() {

            $('#qeleven-div').hide();
            $('#qtwelve-div').hide();
            $('#qfifteen-div').hide();
            $('#qtwentyfour-div').hide();
            $('#qthirtythree-div').hide();
            $('#qtwentyfive').removeAttr('required');
            $('#qtwentysix').removeAttr('required');
            $('#qtwentyseven').removeAttr('required');
            $('#qtwentyeight').removeAttr('required');

            $('#qfifteen').removeAttr('required');
            $('#qsixteen').removeAttr('required');
            $('#qseventeen').removeAttr('required');
            $('#qeighteen').removeAttr('required');
            $('#qeleven').removeAttr('required');
            $('#qtwelve').removeAttr('required');
            $('#qthirtyone-div').hide();
            $('#qthirtyone').removeAttr('required');
            $('#qthirtytwo-div').hide();
            $('#qthirtytwo').removeAttr('required');



        });
    </script>

    <script type="text/javascript">
        $(function() {
            $('input:radio[name="qtwentythree"]').change(function () {
                if ($(this).val() == 'Central Server') {
                    $('#qtwentyfour-div').show();
                    $('#qtwentyfive').attr('required', 'required');
                    $('#qtwentysix').attr('required', 'required');
                    $('#qtwentyseven').attr('required', 'required');
                    $('#qtwentyeight').attr('required', 'required');
                } else {
                    $('#qtwentyfour-div').hide();
                    $('#qtwentyfive').removeAttr('required');
                    $('#qtwentysix').removeAttr('required');
                    $('#qtwentyseven').removeAttr('required');
                    $('#qtwentyeight').removeAttr('required');
                }
            });
        });
        $(function() {
            $('input:radio[name="qfourteen"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qfifteen-div').show();
                    $('#qfifteen').attr('required', 'required');
                    $('#qsixteen').attr('required', 'required');
                    $('#qseventeen').attr('required', 'required');
                    $('#qeighteen').attr('required', 'required');
                } else {
                    $('#qfifteen-div').hide();
                    $('#qfifteen').removeAttr('required');
                    $('#qsixteen').removeAttr('required');
                    $('#qseventeen').removeAttr('required');
                    $('#qeighteen').removeAttr('required');
                }
            });
        });

        $(function() {
            $('input:radio[name="qten"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qeleven-div').show();
                    $('#qtwelve-div').show();
                    $('#qeleven').attr('required', 'required');
                    $('#qtwelve').attr('required', 'required');
                } else {
                    $('#qeleven-div').hide();
                    $('#qtwelve-div').hide();
                    $('#qeleven').removeAttr('required');
                    $('#qtwelve').removeAttr('required');
                }
            });
        });

        $(function() {

            $('input:radio[name="qtwo"]').change(function() {
                if ($(this).val() == 'Thermal') {
                    $('#qthirtythree-div').show();
                    $('#qthirtythreefile').attr('required', 'required');

                } else {
                    $('#qthirtythree-div').hide();
                    $('#qthirtythreefile').removeAttr('required');

                }
            });
        });


        $(function() {

            $('input:radio[name="qthirty"]').change(function() {
                if ($(this).val() == 'Amjay is building us a website') {
                    $('#qthirtyone-div').hide();
                    $('#qthirtyone').removeAttr('required');

                    $('#qthirtytwo-div').show();
                    $('#qthirtytwo').attr('required', 'required');


                } else {

                    if($(this).val() == 'We have a pharmacy website'){
                        $('#qthirtyone-div').show();
                        $('#qthirtyone').attr('required', 'required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');


                    }else {
                        $('#qthirtyone-div').hide();
                        $('#qthirtyone').removeAttr('required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');
                    }

                }
            });
        });
    </script>

    <style>
        .m-signature-pad--body canvas {
            position: relative;
            left: 0;
            top: 0;
            width: 100%;
            height: 250px;
            border: 1px solid #CCCCCC;
        }

    </style>
    <div class="w3-container">
        <div class="bg-contact2">
            <div class="container-contact2">
                <div class="wrap-contact2">
                    <form class="contact2-form validate-form" method="POST" action="agreement_process.php">

					<span class="contact2-form-title">
Central Profile Software Configuration: WINRX VERSION				</span>


                        <div>
                            <input type="hidden" id="formsubmit" name="formsubmit" value="true">
                            <input type="hidden" id="methodid" name="methodid" value="<?php echo $methodid; ?>" required>
                            <input type="hidden" id="pms" name="pms" value="<?php echo $pms; ?>">


                            <div class="wrap-input2 validate-input" id="pharmacyname-div">
                                <label class="millie-input" data-placeholder="">Pharmacy Name<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="pharmacyname" id="pharmacyname" value="<?php echo $pharmacyname; ?>" readonly>
                            </div>

                            <u><span>Please complete and submit this form to ensure Amjay Software properly
configures all features to your specific pharmacy. Please note: we require
this document to be completed before the installation date can be booked
at your pharmacy.</span></u><br><br>


                            <div class="wrap-input2 validate-input" id="qtwo-div">

                                <strong><span class="millie-input2">Type of Printer:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwo-op1" name="qtwo" value="Thermal" required>
                                <span for="qtwo-op1">Thermal </span>			<br>

                                <input type="radio" id="qtwo-op2" name="qtwo" value="Laser printer">
                                <span for="qtwo-op2">Laser printer</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtythree-div">
                                <label class="millie-input" data-placeholder="">(If thermal, please send us a picture of the label or receipt depending on
                                    where you want to print the card)
                                    is on file within their patient profile of your pharmacy **must be png<span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qthirtythreefile" id="qthirtythreefile" accept=".png">
                                <input type="hidden" name="qthirtythree" id="qthirtythree" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthree-div">
                                <label class="millie-input" data-placeholder="">How many digits are in the Rx #'s? <span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qthree" id="qthree" required>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfour-div">
                                <label class="millie-input" data-placeholder="">Windows Store Admin Password <span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfour" id="qfour" >
                            </div>

                            <div class="wrap-input2 validate-input" id="qseven-div">
                                <label class="millie-input" data-placeholder="">Please send us a picture of a sample receipt with a barcode: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qseventext" id="qseventext" accept=".png" required>
                                <input class="input2" type="hidden" name="qseven" id="qseven" >

                            </div>


                            <div class="wrap-input2 validate-input" id="qfive-div">
                                <strong><span class="millie-input2">Do you use original # on rx number?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfive-op1" name="qfive" value="yes" required>
                                <span for="qfive-op1">Yes</span>			<br>
                                <input type="radio" id="qfive-op2" name="qfive" value="no">
                                <span for="qfive-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qsix-div">
                                <label class="millie-input" data-placeholder="">How many terminals do you have?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qsix" id="qsix" required>
                            </div>


                            <div class="wrap-input2 validate-input" id="qnine-div">
                                <label class="millie-input" data-placeholder="">What P.O.S system do you use for barcode scanning?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qnine" id="qnine" required >
                            </div>

                            <div class="wrap-input2 validate-input" id="qten-div">
                                <strong><span class="millie-input2">Is Amjay Software developing your pharmacy app?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qten-op1" name="qten" value="yes" required>
                                <span for="qten-op1">Yes</span>			<br>
                                <input type="radio" id="qten-op2" name="qten" value="no">
                                <span for="qten-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qeleven-div">
                                <strong><span class="millie-input2">For the feature of sending in a picture of a new Rx from your pharmacy App, where
                            would you like the picture of the Rx to be sent to?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qeleven-op1" name="qeleven" value="To my Fax">
                                <span for="qeleven-op1">To my Fax</span>			<br>
                                <input type="radio" id="qeleven-op2" name="qeleven" value="To my email">
                                <span for="qeleven-op2">To my email</span><br>
                                <input type="radio" id="qeleven-op3" name="qeleven" value="Directly To Kroll">
                                <span for="qeleven-op3">Directly to Kroll</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwelve-div">
                                <label class="millie-input" data-placeholder="">Fax Number OR Email Address:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwelve" id="qtwelve">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirteen-div">
                                <label class="millie-input" data-placeholder="">Please create a test patient in your database using the following instructions:
                                    <br>(NAME IS CASE SENSITIVE)
                                    <br>○ Last name: Unknown
                                    <br>○ First name: NewRx
                                    <br>○ Fill 2 prescriptions<span style="color:red;">*</span></label><br>

                                <input type="checkbox" >
                                <label class="millie" style="color:red">DONE</label>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfourteen-div">
                                <strong><span class="millie-input2">Is there an IT department managing your main server access?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfourteen-op1" name="qfourteen" value="yes" required>
                                <span for="qfourteen-op1">Yes</span>			<br>
                                <input type="radio" id="qfourteen-op2" name="qfourteen" value="no">
                                <span for="qfourteen-op2">No</span>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfifteen-div">
                                <span>Please provide the contact information for the IT department we should contact to get a
                            team viewer to your main server when it’s time to install the software</span><br>

                                <label class="millie-input" data-placeholder="">IT company name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfifteen" id="qfifteen">

                                <label class="millie-input" data-placeholder="">Contact person name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qsixteen" id="qsixteen">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qseventeen" id="qseventeen" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qeighteen" id="qeighteen" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">
                            </div>

                            <div class="wrap-input2 validate-input" id="qnineteen-div">
                                <strong><span>Please indicate the pharmacy staff member we should contact to get a team viewer to
your main server when it’s time to install the software</span></strong><br><br>

                                <label class="millie-input" data-placeholder="">Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwenty" id="qtwenty">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyone" id="qtwentyone" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                                <label class="millie-input" data-placeholder="">Cell Phone:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentytwo" id="qtwentytwo" maxlength="10">
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentythree-div">
                                <strong><span class="millie-input2">Is the pharmacy main server shared with other locations (central server for multiple pharmacies)? Or is the pharmacy’s main server used for this single pharmacy location only?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwentythree-op1" name="qtwentythree" value="Central Server">
                                <span for="qtwentythree-op1">Central Server</span>			<br>
                                <input type="radio" id="qtwentythree-op2" name="qtwentythree" value="Single Server">
                                <span for="qtwentythree-op2">Single Server </span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentyfour-div">
                                <span>Please provide the contact info for the location/pharmacy where your central server resides?</span><br>

                                <label class="millie-input" data-placeholder="">Location of Central Server:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyfive" id="qtwentyfive">

                                <label class="millie-input" data-placeholder="">Contact Person Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentysix" id="qtwentysix">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentyseven" id="qtwentyseven" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyeight" id="qtwentyeight" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                            </div>


                            <div class="wrap-input2 validate-input" id="qtwentynine-div">
                                <label class="millie-input" data-placeholder="">Please submit a pharmacy logo: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qtwentyninefile" id="qtwentyninefile" accept=".png" required>
                                <input type="hidden" name="qtwentynine" id="qtwentynine" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirty-div">
                                <strong><span class="millie-input2">Does your pharmacy have an existing website or will Amjay be developing one for you?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qthirty-op1" name="qthirty" value="We have a pharmacy website">
                                <span for="qthirty-op1">We have a pharmacy website</span>			<br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="Amjay is building us a website">
                                <span for="qthirty-op2">Amjay is building us a website</span>       <br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="We do not want a website at this time">
                                <span for="qthirty-op2">We do not want a website at this time</span>
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirtyone-div">
                                <label class="millie-input" data-placeholder="">Website Domain:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtyone" id="qthirtyone">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtytwo-div">
                                <label class="millie-input" data-placeholder="">Provide
                                    recommendations for what they would like as a new domain):<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtytwo" id="qthirtytwo">
                            </div>


                            <div class="wrap-input2 validate-input" id="signdate">
                                <strong><span class="millie-input2" for="datesigned"> Date of Signature </span></strong>
                                <input class="input2" type="text" name="datesigned" id="datesigned" readonly>
                            </div>


                            <script>
                                $( document ).ready(function() {

                                    var today = new Date();
                                    var dd = today.getDate();

                                    var mm = today.getMonth()+1;
                                    var yyyy = today.getFullYear();
                                    if(dd<10)
                                    {
                                        dd='0'+dd;
                                    }

                                    if(mm<10)
                                    {
                                        mm='0'+mm;
                                    }
                                    today = yyyy+'-'+mm+'-'+dd;
                                    console.log(today);

                                    $('input:text[name="datesigned"]').val(today);
                                });
                            </script>

                            <strong><span class="millie-input21" for="signaturestuff" style="font-size:15px;">Sign Here</span></strong>
                            <div id="signature-pad" class="m-signature-pad">
                                <div class="m-signature-pad--body">
                                    <canvas></canvas>
                                    <input type="hidden" name="signature" id="signature" value="">
                                </div>
                            </div>

                            <button type="button" class="btn btn-primary" onclick="signaturePad.clear();">Clear Signature</button>


                            <script src="js/signature_pad.js"></script>
                            <script type="text/javascript">
                                var wrapper = document.getElementById("signature-pad"),
                                    canvas = wrapper.querySelector("canvas"),
                                    signaturePad;


                                function resizeCanvas() {
                                    var oldContent = signaturePad.toData();
                                    var ratio =  Math.max(window.devicePixelRatio || 1, 1);
                                    canvas.width = canvas.offsetWidth * ratio;
                                    canvas.height = canvas.offsetHeight * ratio;
                                    canvas.getContext("2d").scale(ratio, ratio);
                                    signaturePad.clear();
                                    signaturePad.fromData(oldContent);
                                }



                                function download(filename) {
                                    var blob = dataURLToBlob(signaturePad.toDataURL());
                                    var url = window.URL.createObjectURL(blob);

                                    var a = document.createElement("a");
                                    a.style = "display: none";
                                    a.href = url;
                                    a.download = filename;

                                    document.body.appendChild(a);
                                    a.click();

                                    window.URL.revokeObjectURL(url);
                                }


                                function dataURLToBlob(dataURL) {
                                    var parts = dataURL.split(';base64,');
                                    var contentType = parts[0].split(":")[1];
                                    var raw = window.atob(parts[1]);
                                    var rawLength = raw.length;
                                    var uInt8Array = new Uint8Array(rawLength);

                                    for (var i = 0; i < rawLength; ++i) {
                                        uInt8Array[i] = raw.charCodeAt(i);
                                    }

                                    return new Blob([uInt8Array], { type: contentType });
                                }

                                File.prototype.convertToBase64 = function(callback){
                                    var reader = new FileReader();
                                    reader.onloadend = function (e) {
                                        callback(e.target.result, e.target.error);
                                    };
                                    reader.readAsDataURL(this);
                                };

                                $("#qseventext").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qseven').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qtwentyninefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qtwentynine').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qthirtythreefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qthirtythree').value = base64;
                                        console.log(base64);

                                    })
                                });




                                function submitForm() {
                                    document.getElementById('signature').value = signaturePad.toDataURL();

                                }


                                var signaturePad = new SignaturePad(canvas);
                                signaturePad.minWidth = 1;
                                signaturePad.maxWidth = 5;
                                signaturePad.penColor = "#000000";
                                signaturePad.backgroundColor = "#FFFFFF";

                                window.onresize = resizeCanvas;
                                resizeCanvas();

                            </script><br>
                            <div class="container-contact2-form-btn">
                                <div class="wrap-contact2-form-btn">
                                    <div class="contact2-form-bgbtn" id="endbtn"></div>
                                    <input type="submit" class="btn btn-primary" onclick="submitForm()" >
                                </div>
                            </div>


                    </form>
                </div>
            </div>
        </div>
    </div>
    <!--===============================================================================================-->
    <!--===============================================================================================-->
    <script src="vendor/bootstrap/js/popper.js"></script>
    <script src="vendor/bootstrap/js/bootstrap.min.js"></script>
    <!--===============================================================================================-->
    <script src="vendor/select2/select2.min.js"></script>
    <!--===============================================================================================-->
    <script src="js/main.js"></script>
    <script src="js/signature_pad.js" type="text/javascript"></script>



    <?php
}
if($pms=='fillware' or $pms=="propelrx"){?>

    <!-- Bootstrap CSS -->
    <link href="css/bootstrap.min.css" rel="stylesheet">
    <link href="css/font-awesome.min.css" rel="stylesheet">
    <link rel="stylesheet" type="text/css" href="css/util.css">
    <link rel="stylesheet" type="text/css" href="css/main.css">
    <link href="css/w3.css" type="text/css" rel="stylesheet" />
    <script src="js/the-datepicker.min.js"></script>
    <link rel="stylesheet" href="css/the-datepicker.css">
    <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.1/jquery.min.js"></script>
    <script>

        $( document ).ready(function() {

            $('#qeleven-div').hide();
            $('#qtwelve-div').hide();
            $('#qfifteen-div').hide();
            $('#qtwentyfour-div').hide();
            $('#qthirtythree-div').hide();
            $('#qtwentyfive').removeAttr('required');
            $('#qtwentysix').removeAttr('required');
            $('#qtwentyseven').removeAttr('required');
            $('#qtwentyeight').removeAttr('required');

            $('#qfifteen').removeAttr('required');
            $('#qsixteen').removeAttr('required');
            $('#qseventeen').removeAttr('required');
            $('#qeighteen').removeAttr('required');
            $('#qeleven').removeAttr('required');
            $('#qtwelve').removeAttr('required');
            $('#qthirtyone-div').hide();
            $('#qthirtyone').removeAttr('required');
            $('#qthirtytwo-div').hide();
            $('#qthirtytwo').removeAttr('required');



        });
    </script>

    <script type="text/javascript">
        $(function() {
            $('input:radio[name="qtwentythree"]').change(function () {
                if ($(this).val() == 'Central Server') {
                    $('#qtwentyfour-div').show();
                    $('#qtwentyfive').attr('required', 'required');
                    $('#qtwentysix').attr('required', 'required');
                    $('#qtwentyseven').attr('required', 'required');
                    $('#qtwentyeight').attr('required', 'required');
                } else {
                    $('#qtwentyfour-div').hide();
                    $('#qtwentyfive').removeAttr('required');
                    $('#qtwentysix').removeAttr('required');
                    $('#qtwentyseven').removeAttr('required');
                    $('#qtwentyeight').removeAttr('required');
                }
            });
        });
        $(function() {
            $('input:radio[name="qfourteen"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qfifteen-div').show();
                    $('#qfifteen').attr('required', 'required');
                    $('#qsixteen').attr('required', 'required');
                    $('#qseventeen').attr('required', 'required');
                    $('#qeighteen').attr('required', 'required');
                } else {
                    $('#qfifteen-div').hide();
                    $('#qfifteen').removeAttr('required');
                    $('#qsixteen').removeAttr('required');
                    $('#qseventeen').removeAttr('required');
                    $('#qeighteen').removeAttr('required');
                }
            });
        });

        $(function() {
            $('input:radio[name="qten"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qeleven-div').show();
                    $('#qtwelve-div').show();
                    $('#qeleven').attr('required', 'required');
                    $('#qtwelve').attr('required', 'required');
                } else {
                    $('#qeleven-div').hide();
                    $('#qtwelve-div').hide();
                    $('#qeleven').removeAttr('required');
                    $('#qtwelve').removeAttr('required');
                }
            });
        });

        $(function() {

            $('input:radio[name="qtwo"]').change(function() {
                if ($(this).val() == 'Thermal') {
                    $('#qthirtythree-div').show();
                    $('#qthirtythreefile').attr('required', 'required');

                } else {
                    $('#qthirtythree-div').hide();
                    $('#qthirtythreefile').removeAttr('required');

                }
            });
        });


        $(function() {

            $('input:radio[name="qthirty"]').change(function() {
                if ($(this).val() == 'Amjay is building us a website') {
                    $('#qthirtyone-div').hide();
                    $('#qthirtyone').removeAttr('required');

                    $('#qthirtytwo-div').show();
                    $('#qthirtytwo').attr('required', 'required');


                } else {

                    if($(this).val() == 'We have a pharmacy website'){
                        $('#qthirtyone-div').show();
                        $('#qthirtyone').attr('required', 'required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');


                    }else {
                        $('#qthirtyone-div').hide();
                        $('#qthirtyone').removeAttr('required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');
                    }

                }
            });
        });
    </script>

    <style>
        .m-signature-pad--body canvas {
            position: relative;
            left: 0;
            top: 0;
            width: 100%;
            height: 250px;
            border: 1px solid #CCCCCC;
        }

    </style>
    <div class="w3-container">
        <div class="bg-contact2">
            <div class="container-contact2">
                <div class="wrap-contact2">
                    <form class="contact2-form validate-form" method="POST" action="agreement_process.php">

					<span class="contact2-form-title">
Central Profile Software Configuration: FILLWARE/PROPELRX VERSION				</span>


                        <div>
                            <input type="hidden" id="formsubmit" name="formsubmit" value="true">
                            <input type="hidden" id="methodid" name="methodid" value="<?php echo $methodid; ?>" required>
                            <input type="hidden" id="pms" name="pms" value="<?php echo $pms; ?>">


                            <div class="wrap-input2 validate-input" id="pharmacyname-div">
                                <label class="millie-input" data-placeholder="">Pharmacy Name<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="pharmacyname" id="pharmacyname" value="<?php echo $pharmacyname; ?>" readonly>
                            </div>

                            <u><span>Please complete and submit this form to ensure Amjay Software properly
configures all features to your specific pharmacy. Please note: we require
this document to be completed before the installation date can be booked
at your pharmacy.</span></u><br><br>

                            <div class="wrap-input2 validate-input" id="qone-div">
                                <strong><span class="millie-input2">Please select from one of the call flows below for your pharmacy’s Phone IVR Rx
refill call flow configuration:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qone-op1" name="qone" value="Patients are prompted to enter their Rx number and phone number that
is on file within their patient profile of your pharmacy" required>
                                <span for="prepare">Patients are prompted to enter their Rx number and phone number that
is on file within their patient profile of your pharmacy</span>			<br>

                                <input type="radio" id="qone-op2" name="qone" value="Patients are prompted to enter their Rx number and the IVR reads the
birthday on file associated with that Rx number and prompts the patient
to validate.">
                                <span for="qone-op2">Patients are prompted to enter their Rx number and the IVR reads the
birthday on file associated with that Rx number and prompts the patient
to validate.</span>
                            </div>




                            <div class="wrap-input2 validate-input" id="qtwo-div">

                                <strong><span class="millie-input2">Type of Printer:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwo-op1" name="qtwo" value="Thermal" required>
                                <span for="qtwo-op1">Thermal </span>			<br>

                                <input type="radio" id="qtwo-op2" name="qtwo" value="Laser printer">
                                <span for="qtwo-op2">Laser printer</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtythree-div">
                                <label class="millie-input" data-placeholder="">(If thermal, please send us a picture of the label or receipt depending on
                                    where you want to print the card)
                                    is on file within their patient profile of your pharmacy **must be png<span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qthirtythreefile" id="qthirtythreefile" accept=".png">
                                <input type="hidden" name="qthirtythree" id="qthirtythree" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthree-div">
                                <label class="millie-input" data-placeholder="">How many digits are in the Rx #'s? <span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qthree" id="qthree" required>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfour-div">
                                <label class="millie-input" data-placeholder="">Windows Store Admin Password <span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfour" id="qfour" >
                            </div>

                            <div class="wrap-input2 validate-input" id="qseven-div">
                                <label class="millie-input" data-placeholder="">Please send us a picture of a sample receipt with a barcode: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qseventext" id="qseventext" accept=".png" required>
                                <input class="input2" type="hidden" name="qseven" id="qseven" >

                            </div>


                            <div class="wrap-input2 validate-input" id="qfive-div">
                                <strong><span class="millie-input2">Do you use original # on rx number?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfive-op1" name="qfive" value="yes" required>
                                <span for="qfive-op1">Yes</span>			<br>
                                <input type="radio" id="qfive-op2" name="qfive" value="no">
                                <span for="qfive-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qsix-div">
                                <label class="millie-input" data-placeholder="">How many terminals do you have?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qsix" id="qsix" required>
                            </div>


                            <div class="wrap-input2 validate-input" id="qnine-div">
                                <label class="millie-input" data-placeholder="">What P.O.S system do you use for barcode scanning?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qnine" id="qnine" required >
                            </div>

                            <div class="wrap-input2 validate-input" id="qten-div">
                                <strong><span class="millie-input2">Is Amjay Software developing your pharmacy app?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qten-op1" name="qten" value="yes" required>
                                <span for="qten-op1">Yes</span>			<br>
                                <input type="radio" id="qten-op2" name="qten" value="no">
                                <span for="qten-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qeleven-div">
                                <strong><span class="millie-input2">For the feature of sending in a picture of a new Rx from your pharmacy App, where
                            would you like the picture of the Rx to be sent to?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qeleven-op1" name="qeleven" value="To my Fax">
                                <span for="qeleven-op1">To my Fax</span>			<br>
                                <input type="radio" id="qeleven-op2" name="qeleven" value="To my email">
                                <span for="qeleven-op2">To my email</span><br>
                                <input type="radio" id="qeleven-op3" name="qeleven" value="Directly To Kroll">
                                <span for="qeleven-op3">Directly to Kroll</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwelve-div">
                                <label class="millie-input" data-placeholder="">Fax Number OR Email Address:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwelve" id="qtwelve">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirteen-div">
                                <label class="millie-input" data-placeholder="">Please create a test patient in your database using the following instructions:
                                    <br>(NAME IS CASE SENSITIVE)
                                    <br>○ Last name: Unknown
                                    <br>○ First name: NewRx
                                    <br>○ Fill 2 prescriptions<span style="color:red;">*</span></label><br>

                                <input type="checkbox" >
                                <label class="millie" style="color:red">DONE</label>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfourteen-div">
                                <strong><span class="millie-input2">Is there an IT department managing your main server access?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfourteen-op1" name="qfourteen" value="yes" required>
                                <span for="qfourteen-op1">Yes</span>			<br>
                                <input type="radio" id="qfourteen-op2" name="qfourteen" value="no">
                                <span for="qfourteen-op2">No</span>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfifteen-div">
                                <span>Please provide the contact information for the IT department we should contact to get a
                            team viewer to your main server when it’s time to install the software</span><br>

                                <label class="millie-input" data-placeholder="">IT company name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfifteen" id="qfifteen">

                                <label class="millie-input" data-placeholder="">Contact person name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qsixteen" id="qsixteen">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qseventeen" id="qseventeen" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qeighteen" id="qeighteen" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">
                            </div>

                            <div class="wrap-input2 validate-input" id="qnineteen-div">
                                <strong><span>Please indicate the pharmacy staff member we should contact to get a team viewer to
your main server when it’s time to install the software</span></strong><br><br>

                                <label class="millie-input" data-placeholder="">Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwenty" id="qtwenty">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyone" id="qtwentyone" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                                <label class="millie-input" data-placeholder="">Cell Phone:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentytwo" id="qtwentytwo" maxlength="10">
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentythree-div">
                                <strong><span class="millie-input2">Is the pharmacy main server shared with other locations (central server for multiple pharmacies)? Or is the pharmacy’s main server used for this single pharmacy location only?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwentythree-op1" name="qtwentythree" value="Central Server">
                                <span for="qtwentythree-op1">Central Server</span>			<br>
                                <input type="radio" id="qtwentythree-op2" name="qtwentythree" value="Single Server">
                                <span for="qtwentythree-op2">Single Server </span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentyfour-div">
                                <span>Please provide the contact info for the location/pharmacy where your central server resides?</span><br>

                                <label class="millie-input" data-placeholder="">Location of Central Server:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyfive" id="qtwentyfive">

                                <label class="millie-input" data-placeholder="">Contact Person Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentysix" id="qtwentysix">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentyseven" id="qtwentyseven" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyeight" id="qtwentyeight" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                            </div>


                            <div class="wrap-input2 validate-input" id="qtwentynine-div">
                                <label class="millie-input" data-placeholder="">Please submit a pharmacy logo: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qtwentyninefile" id="qtwentyninefile" accept=".png" required>
                                <input type="hidden" name="qtwentynine" id="qtwentynine" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirty-div">
                                <strong><span class="millie-input2">Does your pharmacy have an existing website or will Amjay be developing one for you?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qthirty-op1" name="qthirty" value="We have a pharmacy website">
                                <span for="qthirty-op1">We have a pharmacy website</span>			<br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="Amjay is building us a website">
                                <span for="qthirty-op2">Amjay is building us a website</span>       <br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="We do not want a website at this time">
                                <span for="qthirty-op2">We do not want a website at this time</span>
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirtyone-div">
                                <label class="millie-input" data-placeholder="">Website Domain:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtyone" id="qthirtyone">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtytwo-div">
                                <label class="millie-input" data-placeholder="">Provide
                                    recommendations for what they would like as a new domain):<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtytwo" id="qthirtytwo">
                            </div>


                            <div class="wrap-input2 validate-input" id="signdate">
                                <strong><span class="millie-input2" for="datesigned"> Date of Signature </span></strong>
                                <input class="input2" type="text" name="datesigned" id="datesigned" readonly>
                            </div>


                            <script>
                                $( document ).ready(function() {

                                    var today = new Date();
                                    var dd = today.getDate();

                                    var mm = today.getMonth()+1;
                                    var yyyy = today.getFullYear();
                                    if(dd<10)
                                    {
                                        dd='0'+dd;
                                    }

                                    if(mm<10)
                                    {
                                        mm='0'+mm;
                                    }
                                    today = yyyy+'-'+mm+'-'+dd;
                                    console.log(today);

                                    $('input:text[name="datesigned"]').val(today);
                                });
                            </script>

                            <strong><span class="millie-input21" for="signaturestuff" style="font-size:15px;">Sign Here</span></strong>
                            <div id="signature-pad" class="m-signature-pad">
                                <div class="m-signature-pad--body">
                                    <canvas></canvas>
                                    <input type="hidden" name="signature" id="signature" value="">
                                </div>
                            </div>

                            <button type="button" class="btn btn-primary" onclick="signaturePad.clear();">Clear Signature</button>


                            <script src="js/signature_pad.js"></script>
                            <script type="text/javascript">
                                var wrapper = document.getElementById("signature-pad"),
                                    canvas = wrapper.querySelector("canvas"),
                                    signaturePad;


                                function resizeCanvas() {
                                    var oldContent = signaturePad.toData();
                                    var ratio =  Math.max(window.devicePixelRatio || 1, 1);
                                    canvas.width = canvas.offsetWidth * ratio;
                                    canvas.height = canvas.offsetHeight * ratio;
                                    canvas.getContext("2d").scale(ratio, ratio);
                                    signaturePad.clear();
                                    signaturePad.fromData(oldContent);
                                }



                                function download(filename) {
                                    var blob = dataURLToBlob(signaturePad.toDataURL());
                                    var url = window.URL.createObjectURL(blob);

                                    var a = document.createElement("a");
                                    a.style = "display: none";
                                    a.href = url;
                                    a.download = filename;

                                    document.body.appendChild(a);
                                    a.click();

                                    window.URL.revokeObjectURL(url);
                                }


                                function dataURLToBlob(dataURL) {
                                    var parts = dataURL.split(';base64,');
                                    var contentType = parts[0].split(":")[1];
                                    var raw = window.atob(parts[1]);
                                    var rawLength = raw.length;
                                    var uInt8Array = new Uint8Array(rawLength);

                                    for (var i = 0; i < rawLength; ++i) {
                                        uInt8Array[i] = raw.charCodeAt(i);
                                    }

                                    return new Blob([uInt8Array], { type: contentType });
                                }

                                File.prototype.convertToBase64 = function(callback){
                                    var reader = new FileReader();
                                    reader.onloadend = function (e) {
                                        callback(e.target.result, e.target.error);
                                    };
                                    reader.readAsDataURL(this);
                                };

                                $("#qseventext").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qseven').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qtwentyninefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qtwentynine').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qthirtythreefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qthirtythree').value = base64;
                                        console.log(base64);

                                    })
                                });




                                function submitForm() {
                                    document.getElementById('signature').value = signaturePad.toDataURL();

                                }


                                var signaturePad = new SignaturePad(canvas);
                                signaturePad.minWidth = 1;
                                signaturePad.maxWidth = 5;
                                signaturePad.penColor = "#000000";
                                signaturePad.backgroundColor = "#FFFFFF";

                                window.onresize = resizeCanvas;
                                resizeCanvas();

                            </script><br>
                            <div class="container-contact2-form-btn">
                                <div class="wrap-contact2-form-btn">
                                    <div class="contact2-form-bgbtn" id="endbtn"></div>
                                    <input type="submit" class="btn btn-primary" onclick="submitForm()" >
                                </div>
                            </div>


                    </form>
                </div>
            </div>
        </div>
    </div>
    <!--===============================================================================================-->
    <!--===============================================================================================-->
    <script src="vendor/bootstrap/js/popper.js"></script>
    <script src="vendor/bootstrap/js/bootstrap.min.js"></script>
    <!--===============================================================================================-->
    <script src="vendor/select2/select2.min.js"></script>
    <!--===============================================================================================-->
    <script src="js/main.js"></script>
    <script src="js/signature_pad.js" type="text/javascript"></script>







    <?php
}
if($pms=='pclicknexys'){?>
    <!-- Bootstrap CSS -->
    <link href="css/bootstrap.min.css" rel="stylesheet">
    <link href="css/font-awesome.min.css" rel="stylesheet">
    <link rel="stylesheet" type="text/css" href="css/util.css">
    <link rel="stylesheet" type="text/css" href="css/main.css">
    <link href="css/w3.css" type="text/css" rel="stylesheet" />
    <script src="js/the-datepicker.min.js"></script>
    <link rel="stylesheet" href="css/the-datepicker.css">
    <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.1/jquery.min.js"></script>
    <script>

        $( document ).ready(function() {

            $('#qeleven-div').hide();
            $('#qtwelve-div').hide();
            $('#qfifteen-div').hide();
            $('#qtwentyfour-div').hide();
            $('#qthirtythree-div').hide();
            $('#qtwentyfive').removeAttr('required');
            $('#qtwentysix').removeAttr('required');
            $('#qtwentyseven').removeAttr('required');
            $('#qtwentyeight').removeAttr('required');

            $('#qfifteen').removeAttr('required');
            $('#qsixteen').removeAttr('required');
            $('#qseventeen').removeAttr('required');
            $('#qeighteen').removeAttr('required');
            $('#qeleven').removeAttr('required');
            $('#qtwelve').removeAttr('required');
            $('#qthirtyone-div').hide();
            $('#qthirtyone').removeAttr('required');
            $('#qthirtytwo-div').hide();
            $('#qthirtytwo').removeAttr('required');



        });
    </script>

    <script type="text/javascript">
        $(function() {
            $('input:radio[name="qtwentythree"]').change(function () {
                if ($(this).val() == 'Central Server') {
                    $('#qtwentyfour-div').show();
                    $('#qtwentyfive').attr('required', 'required');
                    $('#qtwentysix').attr('required', 'required');
                    $('#qtwentyseven').attr('required', 'required');
                    $('#qtwentyeight').attr('required', 'required');
                } else {
                    $('#qtwentyfour-div').hide();
                    $('#qtwentyfive').removeAttr('required');
                    $('#qtwentysix').removeAttr('required');
                    $('#qtwentyseven').removeAttr('required');
                    $('#qtwentyeight').removeAttr('required');
                }
            });
        });
        $(function() {
            $('input:radio[name="qfourteen"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qfifteen-div').show();
                    $('#qfifteen').attr('required', 'required');
                    $('#qsixteen').attr('required', 'required');
                    $('#qseventeen').attr('required', 'required');
                    $('#qeighteen').attr('required', 'required');
                } else {
                    $('#qfifteen-div').hide();
                    $('#qfifteen').removeAttr('required');
                    $('#qsixteen').removeAttr('required');
                    $('#qseventeen').removeAttr('required');
                    $('#qeighteen').removeAttr('required');
                }
            });
        });

        $(function() {
            $('input:radio[name="qten"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qeleven-div').show();
                    $('#qtwelve-div').show();
                    $('#qeleven').attr('required', 'required');
                    $('#qtwelve').attr('required', 'required');
                } else {
                    $('#qeleven-div').hide();
                    $('#qtwelve-div').hide();
                    $('#qeleven').removeAttr('required');
                    $('#qtwelve').removeAttr('required');
                }
            });
        });

        $(function() {

            $('input:radio[name="qtwo"]').change(function() {
                if ($(this).val() == 'Thermal') {
                    $('#qthirtythree-div').show();
                    $('#qthirtythreefile').attr('required', 'required');

                } else {
                    $('#qthirtythree-div').hide();
                    $('#qthirtythreefile').removeAttr('required');

                }
            });
        });


        $(function() {

            $('input:radio[name="qthirty"]').change(function() {
                if ($(this).val() == 'Amjay is building us a website') {
                    $('#qthirtyone-div').hide();
                    $('#qthirtyone').removeAttr('required');

                    $('#qthirtytwo-div').show();
                    $('#qthirtytwo').attr('required', 'required');


                } else {

                    if($(this).val() == 'We have a pharmacy website'){
                        $('#qthirtyone-div').show();
                        $('#qthirtyone').attr('required', 'required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');


                    }else {
                        $('#qthirtyone-div').hide();
                        $('#qthirtyone').removeAttr('required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');
                    }

                }
            });
        });
    </script>

    <style>
        .m-signature-pad--body canvas {
            position: relative;
            left: 0;
            top: 0;
            width: 100%;
            height: 250px;
            border: 1px solid #CCCCCC;
        }

    </style>
    <div class="w3-container">
        <div class="bg-contact2">
            <div class="container-contact2">
                <div class="wrap-contact2">
                    <form class="contact2-form validate-form" method="POST" action="agreement_process.php">

					<span class="contact2-form-title">
Central Profile Software Configuration: PCLICK VERSION				</span>


                        <div>
                            <input type="hidden" id="formsubmit" name="formsubmit" value="true">
                            <input type="hidden" id="methodid" name="methodid" value="<?php echo $methodid; ?>" required>
                            <input type="hidden" id="pms" name="pms" value="<?php echo $pms; ?>">


                            <div class="wrap-input2 validate-input" id="pharmacyname-div">
                                <label class="millie-input" data-placeholder="">Pharmacy Name<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="pharmacyname" id="pharmacyname" value="<?php echo $pharmacyname; ?>" readonly>
                            </div>

                            <u><span>Please complete and submit this form to ensure Amjay Software properly
configures all features to your specific pharmacy. Please note: we require
this document to be completed before the installation date can be booked
at your pharmacy.</span></u><br><br>

                            <div class="wrap-input2 validate-input" id="qone-div">
                                <strong><span class="millie-input2">Please select from one of the call flows below for your pharmacy’s Phone IVR Rx
refill call flow configuration:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qone-op1" name="qone" value="Patients are prompted to enter their Rx number and phone number that
is on file within their patient profile of your pharmacy" required>
                                <span for="prepare">Patients are prompted to enter their Rx number and phone number that
is on file within their patient profile of your pharmacy</span>			<br>

                                <input type="radio" id="qone-op2" name="qone" value="Patients are prompted to enter their Rx number and the IVR reads the
birthday on file associated with that Rx number and prompts the patient
to validate.">
                                <span for="qone-op2">Patients are prompted to enter their Rx number and the IVR reads the
birthday on file associated with that Rx number and prompts the patient
to validate.</span>
                            </div>




                            <div class="wrap-input2 validate-input" id="qtwo-div">

                                <strong><span class="millie-input2">Type of Printer:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwo-op1" name="qtwo" value="Thermal" required>
                                <span for="qtwo-op1">Thermal </span>			<br>

                                <input type="radio" id="qtwo-op2" name="qtwo" value="Laser printer">
                                <span for="qtwo-op2">Laser printer</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtythree-div">
                                <label class="millie-input" data-placeholder="">(If thermal, please send us a picture of the label or receipt depending on
                                    where you want to print the card)
                                    is on file within their patient profile of your pharmacy **must be png<span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qthirtythreefile" id="qthirtythreefile" accept=".png">
                                <input type="hidden" name="qthirtythree" id="qthirtythree" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthree-div">
                                <label class="millie-input" data-placeholder="">How many digits are in the Rx #'s? <span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qthree" id="qthree" required>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfour-div">
                                <label class="millie-input" data-placeholder="">Windows Store Admin Password <span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfour" id="qfour" >
                            </div>

                            <div class="wrap-input2 validate-input" id="qseven-div">
                                <label class="millie-input" data-placeholder="">Please send us a picture of a sample receipt with a barcode: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qseventext" id="qseventext" accept=".png" required>
                                <input class="input2" type="hidden" name="qseven" id="qseven" >

                            </div>


                            <div class="wrap-input2 validate-input" id="qfive-div">
                                <strong><span class="millie-input2">Do you use original # on rx number?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfive-op1" name="qfive" value="yes" required>
                                <span for="qfive-op1">Yes</span>			<br>
                                <input type="radio" id="qfive-op2" name="qfive" value="no">
                                <span for="qfive-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qsix-div">
                                <label class="millie-input" data-placeholder="">How many terminals do you have?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qsix" id="qsix" required>
                            </div>

                            <div class="wrap-input2 validate-input" id="qnine-div">
                                <label class="millie-input" data-placeholder="">What P.O.S system do you use for barcode scanning?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qnine" id="qnine" required >
                            </div>

                            <div class="wrap-input2 validate-input" id="qten-div">
                                <strong><span class="millie-input2">Is Amjay Software developing your pharmacy app?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qten-op1" name="qten" value="yes" required>
                                <span for="qten-op1">Yes</span>			<br>
                                <input type="radio" id="qten-op2" name="qten" value="no">
                                <span for="qten-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qeleven-div">
                                <strong><span class="millie-input2">For the feature of sending in a picture of a new Rx from your pharmacy App, where
                            would you like the picture of the Rx to be sent to?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qeleven-op1" name="qeleven" value="To my Fax">
                                <span for="qeleven-op1">To my Fax</span>			<br>
                                <input type="radio" id="qeleven-op2" name="qeleven" value="To my email">
                                <span for="qeleven-op2">To my email</span><br>
                                <input type="radio" id="qeleven-op3" name="qeleven" value="Directly To Kroll">
                                <span for="qeleven-op3">Directly to Kroll</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwelve-div">
                                <label class="millie-input" data-placeholder="">Fax Number OR Email Address:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwelve" id="qtwelve">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirteen-div">
                                <label class="millie-input" data-placeholder="">Please create a test patient in your database using the following instructions:
                                    <br>(NAME IS CASE SENSITIVE)
                                    <br>○ Last name: Unknown
                                    <br>○ First name: NewRx
                                    <br>○ Fill 2 prescriptions<span style="color:red;">*</span></label><br>

                                <input type="checkbox" >
                                <label class="millie" style="color:red">DONE</label>
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtyfour-div">
                                <label class="millie-input" data-placeholder="">Please create a test patient in your database using the following instructions:
                                    <br> Please add a new Pharmacist user in PharmaClick Rx
                                    <br>○ Credentials (case sensitive):
                                    <br> i. username: ONL
                                    <br>○ ii. password: Password1!<span style="color:red;">*</span></label><br>
                                <input type="checkbox" >
                                <label class="millie" style="color:red">DONE</label>
                            </div>

                            <div class="wrap-input2 validate-input" id="qfourteen-div">
                                <strong><span class="millie-input2">Is there an IT department managing your main server access?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfourteen-op1" name="qfourteen" value="yes" required>
                                <span for="qfourteen-op1">Yes</span>			<br>
                                <input type="radio" id="qfourteen-op2" name="qfourteen" value="no">
                                <span for="qfourteen-op2">No</span>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfifteen-div">
                                <span>Please provide the contact information for the IT department we should contact to get a
                            team viewer to your main server when it’s time to install the software</span><br>

                                <label class="millie-input" data-placeholder="">IT company name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfifteen" id="qfifteen">

                                <label class="millie-input" data-placeholder="">Contact person name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qsixteen" id="qsixteen">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qseventeen" id="qseventeen" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qeighteen" id="qeighteen" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">
                            </div>

                            <div class="wrap-input2 validate-input" id="qnineteen-div">
                                <strong><span>Please indicate the pharmacy staff member we should contact to get a team viewer to
your main server when it’s time to install the software</span></strong><br><br>

                                <label class="millie-input" data-placeholder="">Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwenty" id="qtwenty">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyone" id="qtwentyone" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                                <label class="millie-input" data-placeholder="">Cell Phone:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentytwo" id="qtwentytwo" maxlength="10">
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentythree-div">
                                <strong><span class="millie-input2">Is the pharmacy main server shared with other locations (central server for multiple pharmacies)? Or is the pharmacy’s main server used for this single pharmacy location only?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwentythree-op1" name="qtwentythree" value="Central Server">
                                <span for="qtwentythree-op1">Central Server</span>			<br>
                                <input type="radio" id="qtwentythree-op2" name="qtwentythree" value="Single Server">
                                <span for="qtwentythree-op2">Single Server </span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentyfour-div">
                                <span>Please provide the contact info for the location/pharmacy where your central server resides?</span><br>

                                <label class="millie-input" data-placeholder="">Location of Central Server:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyfive" id="qtwentyfive">

                                <label class="millie-input" data-placeholder="">Contact Person Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentysix" id="qtwentysix">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentyseven" id="qtwentyseven" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyeight" id="qtwentyeight" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                            </div>


                            <div class="wrap-input2 validate-input" id="qtwentynine-div">
                                <label class="millie-input" data-placeholder="">Please submit a pharmacy logo: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qtwentyninefile" id="qtwentyninefile" accept=".png" required>
                                <input type="hidden" name="qtwentynine" id="qtwentynine" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirty-div">
                                <strong><span class="millie-input2">Does your pharmacy have an existing website or will Amjay be developing one for you?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qthirty-op1" name="qthirty" value="We have a pharmacy website">
                                <span for="qthirty-op1">We have a pharmacy website</span>			<br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="Amjay is building us a website">
                                <span for="qthirty-op2">Amjay is building us a website</span>       <br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="We do not want a website at this time">
                                <span for="qthirty-op2">We do not want a website at this time</span>
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirtyone-div">
                                <label class="millie-input" data-placeholder="">Website Domain:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtyone" id="qthirtyone">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtytwo-div">
                                <label class="millie-input" data-placeholder="">Provide
                                    recommendations for what they would like as a new domain):<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtytwo" id="qthirtytwo">
                            </div>


                            <div class="wrap-input2 validate-input" id="signdate">
                                <strong><span class="millie-input2" for="datesigned"> Date of Signature </span></strong>
                                <input class="input2" type="text" name="datesigned" id="datesigned" readonly>
                            </div>


                            <script>
                                $( document ).ready(function() {

                                    var today = new Date();
                                    var dd = today.getDate();

                                    var mm = today.getMonth()+1;
                                    var yyyy = today.getFullYear();
                                    if(dd<10)
                                    {
                                        dd='0'+dd;
                                    }

                                    if(mm<10)
                                    {
                                        mm='0'+mm;
                                    }
                                    today = yyyy+'-'+mm+'-'+dd;
                                    console.log(today);

                                    $('input:text[name="datesigned"]').val(today);
                                });
                            </script>

                            <strong><span class="millie-input21" for="signaturestuff" style="font-size:15px;">Sign Here</span></strong>
                            <div id="signature-pad" class="m-signature-pad">
                                <div class="m-signature-pad--body">
                                    <canvas></canvas>
                                    <input type="hidden" name="signature" id="signature" value="">
                                </div>
                            </div>

                            <button type="button" class="btn btn-primary" onclick="signaturePad.clear();">Clear Signature</button>


                            <script src="js/signature_pad.js"></script>
                            <script type="text/javascript">
                                var wrapper = document.getElementById("signature-pad"),
                                    canvas = wrapper.querySelector("canvas"),
                                    signaturePad;


                                function resizeCanvas() {
                                    var oldContent = signaturePad.toData();
                                    var ratio =  Math.max(window.devicePixelRatio || 1, 1);
                                    canvas.width = canvas.offsetWidth * ratio;
                                    canvas.height = canvas.offsetHeight * ratio;
                                    canvas.getContext("2d").scale(ratio, ratio);
                                    signaturePad.clear();
                                    signaturePad.fromData(oldContent);
                                }



                                function download(filename) {
                                    var blob = dataURLToBlob(signaturePad.toDataURL());
                                    var url = window.URL.createObjectURL(blob);

                                    var a = document.createElement("a");
                                    a.style = "display: none";
                                    a.href = url;
                                    a.download = filename;

                                    document.body.appendChild(a);
                                    a.click();

                                    window.URL.revokeObjectURL(url);
                                }


                                function dataURLToBlob(dataURL) {
                                    var parts = dataURL.split(';base64,');
                                    var contentType = parts[0].split(":")[1];
                                    var raw = window.atob(parts[1]);
                                    var rawLength = raw.length;
                                    var uInt8Array = new Uint8Array(rawLength);

                                    for (var i = 0; i < rawLength; ++i) {
                                        uInt8Array[i] = raw.charCodeAt(i);
                                    }

                                    return new Blob([uInt8Array], { type: contentType });
                                }

                                File.prototype.convertToBase64 = function(callback){
                                    var reader = new FileReader();
                                    reader.onloadend = function (e) {
                                        callback(e.target.result, e.target.error);
                                    };
                                    reader.readAsDataURL(this);
                                };

                                $("#qseventext").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qseven').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qtwentyninefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qtwentynine').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qthirtythreefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qthirtythree').value = base64;
                                        console.log(base64);

                                    })
                                });




                                function submitForm() {
                                    document.getElementById('signature').value = signaturePad.toDataURL();

                                }


                                var signaturePad = new SignaturePad(canvas);
                                signaturePad.minWidth = 1;
                                signaturePad.maxWidth = 5;
                                signaturePad.penColor = "#000000";
                                signaturePad.backgroundColor = "#FFFFFF";

                                window.onresize = resizeCanvas;
                                resizeCanvas();

                            </script><br>
                            <div class="container-contact2-form-btn">
                                <div class="wrap-contact2-form-btn">
                                    <div class="contact2-form-bgbtn" id="endbtn"></div>
                                    <input type="submit" class="btn btn-primary" onclick="submitForm()" >
                                </div>
                            </div>


                    </form>
                </div>
            </div>
        </div>
    </div>
    <!--===============================================================================================-->
    <!--===============================================================================================-->
    <script src="vendor/bootstrap/js/popper.js"></script>
    <script src="vendor/bootstrap/js/bootstrap.min.js"></script>
    <!--===============================================================================================-->
    <script src="vendor/select2/select2.min.js"></script>
    <!--===============================================================================================-->
    <script src="js/main.js"></script>
    <script src="js/signature_pad.js" type="text/javascript"></script>







    <?php
}
if($pms == 'kroll') { ?>
    <!-- Bootstrap CSS -->
    <link href="css/bootstrap.min.css" rel="stylesheet">
    <link href="css/font-awesome.min.css" rel="stylesheet">
    <link rel="stylesheet" type="text/css" href="css/util.css">
    <link rel="stylesheet" type="text/css" href="css/main.css">
    <link href="css/w3.css" type="text/css" rel="stylesheet" />
    <script src="js/the-datepicker.min.js"></script>
    <link rel="stylesheet" href="css/the-datepicker.css">
    <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.1/jquery.min.js"></script>
    <script>

    $( document ).ready(function() {

    $('#qeleven-div').hide();
    $('#qtwelve-div').hide();
    $('#qfifteen-div').hide();
    $('#qtwentyfour-div').hide();
    $('#qthirtythree-div').hide();
    $('#qtwentyfive').removeAttr('required');
        $('#qtwentysix').removeAttr('required');
        $('#qtwentyseven').removeAttr('required');
        $('#qtwentyeight').removeAttr('required');

        $('#qfifteen').removeAttr('required');
        $('#qsixteen').removeAttr('required');
        $('#qseventeen').removeAttr('required');
        $('#qeighteen').removeAttr('required');
        $('#qeleven').removeAttr('required');
        $('#qtwelve').removeAttr('required');
        $('#qthirtyone-div').hide();
        $('#qthirtyone').removeAttr('required');
        $('#qthirtytwo-div').hide();
        $('#qthirtytwo').removeAttr('required');



    });
    </script>

    <script type="text/javascript">
        $(function() {
            $('input:radio[name="qtwentythree"]').change(function () {
                if ($(this).val() == 'Central Server') {
                    $('#qtwentyfour-div').show();
                    $('#qtwentyfive').attr('required', 'required');
                    $('#qtwentysix').attr('required', 'required');
                    $('#qtwentyseven').attr('required', 'required');
                    $('#qtwentyeight').attr('required', 'required');
                } else {
                    $('#qtwentyfour-div').hide();
                    $('#qtwentyfive').removeAttr('required');
                    $('#qtwentysix').removeAttr('required');
                    $('#qtwentyseven').removeAttr('required');
                    $('#qtwentyeight').removeAttr('required');
                }
            });
        });
        $(function() {
            $('input:radio[name="qfourteen"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qfifteen-div').show();
                    $('#qfifteen').attr('required', 'required');
                    $('#qsixteen').attr('required', 'required');
                    $('#qseventeen').attr('required', 'required');
                    $('#qeighteen').attr('required', 'required');
                } else {
                    $('#qfifteen-div').hide();
                    $('#qfifteen').removeAttr('required');
                    $('#qsixteen').removeAttr('required');
                    $('#qseventeen').removeAttr('required');
                    $('#qeighteen').removeAttr('required');
                }
            });
        });

        $(function() {
            $('input:radio[name="qten"]').change(function() {
                if ($(this).val() == 'yes') {
                    $('#qeleven-div').show();
                    $('#qtwelve-div').show();
                    $('#qeleven').attr('required', 'required');
                    $('#qtwelve').attr('required', 'required');
                } else {
                    $('#qeleven-div').hide();
                    $('#qtwelve-div').hide();
                    $('#qeleven').removeAttr('required');
                    $('#qtwelve').removeAttr('required');
                }
            });
        });

        $(function() {

        $('input:radio[name="qtwo"]').change(function() {
                if ($(this).val() == 'Thermal') {
                    $('#qthirtythree-div').show();
                    $('#qthirtythreefile').attr('required', 'required');

                } else {
                    $('#qthirtythree-div').hide();
                    $('#qthirtythreefile').removeAttr('required');

                }
            });
        });


        $(function() {

            $('input:radio[name="qthirty"]').change(function() {
                if ($(this).val() == 'Amjay is building us a website') {
                    $('#qthirtyone-div').hide();
                    $('#qthirtyone').removeAttr('required');

                    $('#qthirtytwo-div').show();
                    $('#qthirtytwo').attr('required', 'required');


                } else {

                    if($(this).val() == 'We have a pharmacy website'){
                        $('#qthirtyone-div').show();
                        $('#qthirtyone').attr('required', 'required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');


                    }else {
                        $('#qthirtyone-div').hide();
                        $('#qthirtyone').removeAttr('required');
                        $('#qthirtytwo-div').hide();
                        $('#qthirtytwo').removeAttr('required');
                    }

                }
            });
        });
    </script>

    <style>
        .m-signature-pad--body canvas {
            position: relative;
            left: 0;
            top: 0;
            width: 100%;
            height: 250px;
            border: 1px solid #CCCCCC;
        }

    </style>
    <div class="w3-container">
        <div class="bg-contact2">
            <div class="container-contact2">
                <div class="wrap-contact2">
                    <form class="contact2-form validate-form" method="POST" action="agreement_process.php">

					<span class="contact2-form-title">
Central Profile Software Configuration: KROLL VERSION				</span>


                        <div>
                            <input type="hidden" id="formsubmit" name="formsubmit" value="true">
                            <input type="hidden" id="methodid" name="methodid" value="<?php echo $methodid; ?>" required>
                            <input type="hidden" id="pms" name="pms" value="<?php echo $pms; ?>">


                            <div class="wrap-input2 validate-input" id="pharmacyname-div">
                                <label class="millie-input" data-placeholder="">Pharmacy Name<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="pharmacyname" id="pharmacyname" value="<?php echo $pharmacyname; ?>" readonly>
                            </div>

                            <u><span>Please complete and submit this form to ensure Amjay Software properly
configures all features to your specific pharmacy. Please note: we require
this document to be completed before the installation date can be booked
at your pharmacy.</span></u><br><br>

                            <div class="wrap-input2 validate-input" id="qone-div">
                                <strong><span class="millie-input2">Please select from one of the call flows below for your pharmacy’s Phone IVR Rx
refill call flow configuration:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qone-op1" name="qone" value="Patients are prompted to enter their Rx number and phone number that
is on file within their patient profile of your pharmacy" required>
                                <span for="prepare">Patients are prompted to enter their Rx number and phone number that
is on file within their patient profile of your pharmacy</span>			<br>

                                <input type="radio" id="qone-op2" name="qone" value="Patients are prompted to enter their Rx number and the IVR reads the
birthday on file associated with that Rx number and prompts the patient
to validate.">
                                <span for="qone-op2">Patients are prompted to enter their Rx number and the IVR reads the
birthday on file associated with that Rx number and prompts the patient
to validate.</span>
                            </div>




                            <div class="wrap-input2 validate-input" id="qtwo-div">

                                <strong><span class="millie-input2">Type of Printer:<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwo-op1" name="qtwo" value="Thermal" required>
                                <span for="qtwo-op1">Thermal </span>			<br>

                                <input type="radio" id="qtwo-op2" name="qtwo" value="Laser printer">
                                <span for="qtwo-op2">Laser printer</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtythree-div">
                                <label class="millie-input" data-placeholder="">(If thermal, please send us a picture of the label or receipt depending on
                                    where you want to print the card)
                                    is on file within their patient profile of your pharmacy **must be png<span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qthirtythreefile" id="qthirtythreefile" accept=".png">
                                <input type="hidden" name="qthirtythree" id="qthirtythree" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthree-div">
                                <label class="millie-input" data-placeholder="">How many digits are in the Rx #'s? <span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qthree" id="qthree" required>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfour-div">
                                <label class="millie-input" data-placeholder="">Windows Store Admin Password <span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfour" id="qfour" >
                            </div>

                            <div class="wrap-input2 validate-input" id="qseven-div">
                                <label class="millie-input" data-placeholder="">Please send us a picture of a sample receipt with a barcode: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qseventext" id="qseventext" accept=".png" required>
                                <input class="input2" type="hidden" name="qseven" id="qseven" >

                            </div>


                            <div class="wrap-input2 validate-input" id="qfive-div">
                                <strong><span class="millie-input2">Do you use original # on rx number?<span style="color:red;">*</span></span></strong><br>
                                 <input type="radio" id="qfive-op1" name="qfive" value="yes" required>
                                <span for="qfive-op1">Yes</span>			<br>
                                <input type="radio" id="qfive-op2" name="qfive" value="no">
                                <span for="qfive-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qsix-div">
                                <label class="millie-input" data-placeholder="">How many terminals do you have?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qsix" id="qsix" required>
                            </div>

                            <div class="wrap-input2 validate-input" id="qeight-div">
                                <label class="millie-input" data-placeholder="">What version of Kroll are you running?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qeight" id="qeight" required>
                            </div>

                            <div class="wrap-input2 validate-input" id="qnine-div">
                                <label class="millie-input" data-placeholder="">What P.O.S system do you use for barcode scanning?<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qnine" id="qnine" required >
                            </div>

                            <div class="wrap-input2 validate-input" id="qten-div">
                                <strong><span class="millie-input2">Is Amjay Software developing your pharmacy app?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qten-op1" name="qten" value="yes" required>
                                <span for="qten-op1">Yes</span>			<br>
                                <input type="radio" id="qten-op2" name="qten" value="no">
                                <span for="qten-op2">No</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qeleven-div">
                                <strong><span class="millie-input2">For the feature of sending in a picture of a new Rx from your pharmacy App, where
                            would you like the picture of the Rx to be sent to?<span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qeleven-op1" name="qeleven" value="To my Fax">
                                <span for="qeleven-op1">To my Fax</span>			<br>
                                <input type="radio" id="qeleven-op2" name="qeleven" value="To my email">
                                <span for="qeleven-op2">To my email</span><br>
                                <input type="radio" id="qeleven-op3" name="qeleven" value="Directly To Kroll">
                                <span for="qeleven-op3">Directly to Kroll</span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwelve-div">
                                <label class="millie-input" data-placeholder="">Fax Number OR Email Address:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwelve" id="qtwelve">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirteen-div">
                                <label class="millie-input" data-placeholder="">Please create a test patient in your database using the following instructions:
                                    <br>(NAME IS CASE SENSITIVE)
                                    <br>○ Last name: Unknown
                                    <br>○ First name: NewRx
                                    <br>○ Fill 2 prescriptions<span style="color:red;">*</span></label><br>

                                <input type="checkbox" >
                                <label class="millie" style="color:red">DONE</label>
                            </div>

                            <div class="wrap-input2 validate-input" id="qfourteen-div">
                                <strong><span class="millie-input2">Is there an IT department managing your main server access?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qfourteen-op1" name="qfourteen" value="yes" required>
                                <span for="qfourteen-op1">Yes</span>			<br>
                                <input type="radio" id="qfourteen-op2" name="qfourteen" value="no">
                                <span for="qfourteen-op2">No</span>
                            </div>


                            <div class="wrap-input2 validate-input" id="qfifteen-div">
                                <span>Please provide the contact information for the IT department we should contact to get a
                            team viewer to your main server when it’s time to install the software</span><br>

                                <label class="millie-input" data-placeholder="">IT company name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qfifteen" id="qfifteen">

                                <label class="millie-input" data-placeholder="">Contact person name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qsixteen" id="qsixteen">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qseventeen" id="qseventeen" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qeighteen" id="qeighteen" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">
                            </div>

                            <div class="wrap-input2 validate-input" id="qnineteen-div">
                                <strong><span>Please indicate the pharmacy staff member we should contact to get a team viewer to
your main server when it’s time to install the software</span></strong><br><br>

                                <label class="millie-input" data-placeholder="">Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwenty" id="qtwenty">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyone" id="qtwentyone" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                                <label class="millie-input" data-placeholder="">Cell Phone:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentytwo" id="qtwentytwo" maxlength="10">
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentythree-div">
                                <strong><span class="millie-input2">Is the pharmacy main server shared with other locations (central server for multiple pharmacies)? Or is the pharmacy’s main server used for this single pharmacy location only?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qtwentythree-op1" name="qtwentythree" value="Central Server">
                                <span for="qtwentythree-op1">Central Server</span>			<br>
                                <input type="radio" id="qtwentythree-op2" name="qtwentythree" value="Single Server">
                                <span for="qtwentythree-op2">Single Server </span>
                            </div>

                            <div class="wrap-input2 validate-input" id="qtwentyfour-div">
                                <span>Please provide the contact info for the location/pharmacy where your central server resides?</span><br>

                                <label class="millie-input" data-placeholder="">Location of Central Server:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyfive" id="qtwentyfive">

                                <label class="millie-input" data-placeholder="">Contact Person Name:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentysix" id="qtwentysix">

                                <label class="millie-input" data-placeholder="">Phone #:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="number" name="qtwentyseven" id="qtwentyseven" maxlength="10">

                                <label class="millie-input" data-placeholder="">Email:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qtwentyeight" id="qtwentyeight" pattern="/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3}">

                            </div>


                            <div class="wrap-input2 validate-input" id="qtwentynine-div">
                                <label class="millie-input" data-placeholder="">Please submit a pharmacy logo: **must be png <span style="color:red;">*</span></label><br>
                                <input class="input2" type="file" name="qtwentyninefile" id="qtwentyninefile" accept=".png" required>
                                <input type="hidden" name="qtwentynine" id="qtwentynine" >
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirty-div">
                                <strong><span class="millie-input2">Does your pharmacy have an existing website or will Amjay be developing one for you?
                                        <span style="color:red;">*</span></span></strong><br>
                                <input type="radio" id="qthirty-op1" name="qthirty" value="We have a pharmacy website">
                                <span for="qthirty-op1">We have a pharmacy website</span>			<br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="Amjay is building us a website">
                                <span for="qthirty-op2">Amjay is building us a website</span>       <br>
                                <input type="radio" id="qthirty-op2" name="qthirty" value="We do not want a website at this time">
                                <span for="qthirty-op2">We do not want a website at this time</span>
                            </div>



                            <div class="wrap-input2 validate-input" id="qthirtyone-div">
                                <label class="millie-input" data-placeholder="">Website Domain:<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtyone" id="qthirtyone">
                            </div>

                            <div class="wrap-input2 validate-input" id="qthirtytwo-div">
                                <label class="millie-input" data-placeholder="">Provide
                                    recommendations for what they would like as a new domain):<span style="color:red;">*</span></label><br>
                                <input class="input2" type="text" name="qthirtytwo" id="qthirtytwo">
                            </div>


                            <div class="wrap-input2 validate-input" id="signdate">
                                <strong><span class="millie-input2" for="datesigned"> Date of Signature </span></strong>
                                <input class="input2" type="text" name="datesigned" id="datesigned" readonly>
                            </div>


                            <script>
                                $( document ).ready(function() {

                                    var today = new Date();
                                    var dd = today.getDate();

                                    var mm = today.getMonth()+1;
                                    var yyyy = today.getFullYear();
                                    if(dd<10)
                                    {
                                        dd='0'+dd;
                                    }

                                    if(mm<10)
                                    {
                                        mm='0'+mm;
                                    }
                                    today = yyyy+'-'+mm+'-'+dd;
                                    console.log(today);

                                    $('input:text[name="datesigned"]').val(today);
                                });
                            </script>

                            <strong><span class="millie-input21" for="signaturestuff" style="font-size:15px;">Sign Here</span></strong>
                            <div id="signature-pad" class="m-signature-pad">
                                <div class="m-signature-pad--body">
                                    <canvas></canvas>
                                    <input type="hidden" name="signature" id="signature" value="">
                                </div>
                            </div>

                            <button type="button" class="btn btn-primary" onclick="signaturePad.clear();">Clear Signature</button>


                            <script src="js/signature_pad.js"></script>
                            <script type="text/javascript">
                                var wrapper = document.getElementById("signature-pad"),
                                    canvas = wrapper.querySelector("canvas"),
                                    signaturePad;


                                function resizeCanvas() {
                                    var oldContent = signaturePad.toData();
                                    var ratio =  Math.max(window.devicePixelRatio || 1, 1);
                                    canvas.width = canvas.offsetWidth * ratio;
                                    canvas.height = canvas.offsetHeight * ratio;
                                    canvas.getContext("2d").scale(ratio, ratio);
                                    signaturePad.clear();
                                    signaturePad.fromData(oldContent);
                                }



                                function download(filename) {
                                    var blob = dataURLToBlob(signaturePad.toDataURL());
                                    var url = window.URL.createObjectURL(blob);

                                    var a = document.createElement("a");
                                    a.style = "display: none";
                                    a.href = url;
                                    a.download = filename;

                                    document.body.appendChild(a);
                                    a.click();

                                    window.URL.revokeObjectURL(url);
                                }


                                function dataURLToBlob(dataURL) {
                                    var parts = dataURL.split(';base64,');
                                    var contentType = parts[0].split(":")[1];
                                    var raw = window.atob(parts[1]);
                                    var rawLength = raw.length;
                                    var uInt8Array = new Uint8Array(rawLength);

                                    for (var i = 0; i < rawLength; ++i) {
                                        uInt8Array[i] = raw.charCodeAt(i);
                                    }

                                    return new Blob([uInt8Array], { type: contentType });
                                }

                                File.prototype.convertToBase64 = function(callback){
                                    var reader = new FileReader();
                                    reader.onloadend = function (e) {
                                        callback(e.target.result, e.target.error);
                                    };
                                    reader.readAsDataURL(this);
                                };

                                $("#qseventext").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qseven').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qtwentyninefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qtwentynine').value = base64;
                                        console.log(base64);

                                    })
                                });

                                $("#qthirtythreefile").on('change',function(){
                                    var selectedFile = this.files[0];
                                    selectedFile.convertToBase64(function(base64){
                                        document.getElementById('qthirtythree').value = base64;
                                        console.log(base64);

                                    })
                                });




                                function submitForm() {
                                    document.getElementById('signature').value = signaturePad.toDataURL();

                                }


                                var signaturePad = new SignaturePad(canvas);
                                signaturePad.minWidth = 1;
                                signaturePad.maxWidth = 5;
                                signaturePad.penColor = "#000000";
                                signaturePad.backgroundColor = "#FFFFFF";

                                window.onresize = resizeCanvas;
                                resizeCanvas();

                            </script><br>
                            <div class="container-contact2-form-btn">
                                <div class="wrap-contact2-form-btn">
                                    <div class="contact2-form-bgbtn" id="endbtn"></div>
                                    <input type="submit" class="btn btn-primary" onclick="submitForm()" >
                                </div>
                            </div>


                    </form>
                </div>
            </div>
        </div>
    </div>
    <!--===============================================================================================-->
    <!--===============================================================================================-->
    <script src="vendor/bootstrap/js/popper.js"></script>
    <script src="vendor/bootstrap/js/bootstrap.min.js"></script>
    <!--===============================================================================================-->
    <script src="vendor/select2/select2.min.js"></script>
    <!--===============================================================================================-->
    <script src="js/main.js"></script>
    <script src="js/signature_pad.js" type="text/javascript"></script>





<?php } ?>