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Oct 18th, 2012
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  1. <?xml version="1.0" encoding="UTF-8"?>
  2. <forms version="1.6.8.1">
  3. <form labelPlacement="top_label" useCurrentUserAsAuthor="1">
  4. <title><![CDATA[DE Module Purchase Form]]></title>
  5. <confirmation type="page">
  6. <pageId><![CDATA[945]]></pageId>
  7. </confirmation>
  8. <button type="text">
  9. <text><![CDATA[Submit Order]]></text>
  10. </button>
  11. <fields>
  12. <field id="36" size="medium" type="section" displayOnly="1">
  13. <label><![CDATA[Your Details]]></label>
  14. </field>
  15. <field id="13" isRequired="1" size="medium" type="select" enableChoiceValue="1">
  16. <label><![CDATA[Title]]></label>
  17. <choices>
  18. <choice>
  19. <text><![CDATA[Please select]]></text>
  20. <value><![CDATA[Please select]]></value>
  21. </choice>
  22. <choice>
  23. <text><![CDATA[Dr.]]></text>
  24. <value><![CDATA[Dr.]]></value>
  25. </choice>
  26. <choice>
  27. <text><![CDATA[Mr.]]></text>
  28. <value><![CDATA[Mr.]]></value>
  29. </choice>
  30. <choice>
  31. <text><![CDATA[Mrs.]]></text>
  32. <value><![CDATA[Mrs.]]></value>
  33. </choice>
  34. <choice>
  35. <text><![CDATA[Ms.]]></text>
  36. <value><![CDATA[Ms.]]></value>
  37. </choice>
  38. <choice>
  39. <text><![CDATA[Other]]></text>
  40. <value><![CDATA[Other]]></value>
  41. </choice>
  42. </choices>
  43. </field>
  44. <field id="14" isRequired="1" size="medium" type="name">
  45. <label><![CDATA[Name]]></label>
  46. <inputs>
  47. <input id="14.3">
  48. <label><![CDATA[First]]></label>
  49. </input>
  50. <input id="14.6">
  51. <label><![CDATA[Last]]></label>
  52. </input>
  53. </inputs>
  54. </field>
  55. <field id="15" isRequired="1" size="medium" type="address" addressType="international">
  56. <label><![CDATA[Address]]></label>
  57. <defaultCountry><![CDATA[Australia]]></defaultCountry>
  58. <inputs>
  59. <input id="15.1">
  60. <label><![CDATA[Street Address]]></label>
  61. </input>
  62. <input id="15.2">
  63. <label><![CDATA[Address Line 2]]></label>
  64. </input>
  65. <input id="15.3">
  66. <label><![CDATA[City]]></label>
  67. </input>
  68. <input id="15.4">
  69. <label><![CDATA[State / Province]]></label>
  70. </input>
  71. <input id="15.5">
  72. <label><![CDATA[Post Code]]></label>
  73. </input>
  74. <input id="15.6">
  75. <label><![CDATA[Country]]></label>
  76. </input>
  77. </inputs>
  78. </field>
  79. <field id="16" isRequired="1" size="medium" type="phone" phoneFormat="international">
  80. <defaultValue><![CDATA[( )]]></defaultValue>
  81. <label><![CDATA[Phone]]></label>
  82. </field>
  83. <field id="17" isRequired="1" size="medium" type="email">
  84. <label><![CDATA[Email]]></label>
  85. <emailConfirmEnabled><![CDATA[1]]></emailConfirmEnabled>
  86. </field>
  87. <field id="19" size="medium" type="section" displayOnly="1">
  88. <description><![CDATA[Select one or more of the modules listed below. Prices include GST, packaging & postage. The Risk Management III module and the Clinical Records Audit module are available free of charge to COCA members. To access these modules log in and go to the Membership page.]]></description>
  89. <label><![CDATA[DE Module Purchase Options]]></label>
  90. </field>
  91. <field id="1" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  92. <label><![CDATA[The Back Pain Challenge]]></label>
  93. <basePrice><![CDATA[$ 0.00]]></basePrice>
  94. <choices>
  95. <choice>
  96. <text><![CDATA[Non-Member]]></text>
  97. <value><![CDATA[The Back Pain Challenge Non-Member]]></value>
  98. <price><![CDATA[$ 350.90]]></price>
  99. </choice>
  100. <choice>
  101. <text><![CDATA[Member]]></text>
  102. <value><![CDATA[The Back Pain Challenge Member]]></value>
  103. <price><![CDATA[$ 266.20]]></price>
  104. </choice>
  105. <choice>
  106. <text><![CDATA[CPM]]></text>
  107. <value><![CDATA[The Back Pain Challenge CPM]]></value>
  108. <price><![CDATA[$ 212.96]]></price>
  109. </choice>
  110. </choices>
  111. </field>
  112. <field id="37" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  113. <label><![CDATA[Chronic Musculoskeletal Pain]]></label>
  114. <basePrice><![CDATA[$ 0.00]]></basePrice>
  115. <choices>
  116. <choice>
  117. <text><![CDATA[Non-Member]]></text>
  118. <value><![CDATA[Chronic Musculoskeletal Pain Non-Member]]></value>
  119. <price><![CDATA[$ 484.00]]></price>
  120. </choice>
  121. <choice>
  122. <text><![CDATA[Member]]></text>
  123. <value><![CDATA[Chronic Musculoskeletal Pain Member]]></value>
  124. <price><![CDATA[$ 363.00]]></price>
  125. </choice>
  126. <choice>
  127. <text><![CDATA[CPM]]></text>
  128. <value><![CDATA[Chronic Musculoskeletal Pain CPM]]></value>
  129. <price><![CDATA[$ 290.40]]></price>
  130. </choice>
  131. </choices>
  132. </field>
  133. <field id="38" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  134. <label><![CDATA[Contemporary Practice]]></label>
  135. <basePrice><![CDATA[$ 0.00]]></basePrice>
  136. <choices>
  137. <choice>
  138. <text><![CDATA[Non-Member]]></text>
  139. <value><![CDATA[Contemporary Practice Non-Member]]></value>
  140. <price><![CDATA[$ 484.00]]></price>
  141. </choice>
  142. <choice>
  143. <text><![CDATA[Member]]></text>
  144. <value><![CDATA[Contemporary Practice Member]]></value>
  145. <price><![CDATA[$ 363.00]]></price>
  146. </choice>
  147. <choice>
  148. <text><![CDATA[CPM]]></text>
  149. <value><![CDATA[Contemporary Practice CPM]]></value>
  150. <price><![CDATA[$ 290.40]]></price>
  151. </choice>
  152. </choices>
  153. </field>
  154. <field id="39" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  155. <label><![CDATA[Contra-indications & Complications of SMT]]></label>
  156. <basePrice><![CDATA[$ 0.00]]></basePrice>
  157. <choices>
  158. <choice>
  159. <text><![CDATA[Non-Member]]></text>
  160. <value><![CDATA[Contra-indications & Complications of SMT Non-Member]]></value>
  161. <price><![CDATA[$ 147.62]]></price>
  162. </choice>
  163. <choice>
  164. <text><![CDATA[Member]]></text>
  165. <value><![CDATA[Contra-indications & Complications of SMT Member]]></value>
  166. <price><![CDATA[$ 107.69]]></price>
  167. </choice>
  168. <choice>
  169. <text><![CDATA[CPM]]></text>
  170. <value><![CDATA[Contra-indications & Complications of SMT CPM]]></value>
  171. <price><![CDATA[$ 86.13]]></price>
  172. </choice>
  173. </choices>
  174. </field>
  175. <field id="40" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  176. <label><![CDATA[Current Psychosocial Theories & Interventions]]></label>
  177. <basePrice><![CDATA[$ 0.00]]></basePrice>
  178. <choices>
  179. <choice>
  180. <text><![CDATA[Non-Member]]></text>
  181. <value><![CDATA[Current Psychosocial Theories & Interventions Non-Member]]></value>
  182. <price><![CDATA[$ 225.50]]></price>
  183. </choice>
  184. <choice>
  185. <text><![CDATA[Member]]></text>
  186. <value><![CDATA[Current Psychosocial Theories & Interventions Member]]></value>
  187. <price><![CDATA[$ 181.50]]></price>
  188. </choice>
  189. <choice>
  190. <text><![CDATA[CPM]]></text>
  191. <value><![CDATA[Current Psychosocial Theories & Interventions CPM]]></value>
  192. <price><![CDATA[$ 145.20]]></price>
  193. </choice>
  194. </choices>
  195. </field>
  196. <field id="41" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  197. <label><![CDATA[The Neurological Examination: Headaches & Strokes]]></label>
  198. <basePrice><![CDATA[$ 0.00]]></basePrice>
  199. <choices>
  200. <choice>
  201. <text><![CDATA[Non-Member]]></text>
  202. <value><![CDATA[The Neurological Examination: Headaches & Strokes Non-Member]]></value>
  203. <price><![CDATA[$ 124.63]]></price>
  204. </choice>
  205. <choice>
  206. <text><![CDATA[Member]]></text>
  207. <value><![CDATA[The Neurological Examination: Headaches & Strokes Member]]></value>
  208. <price><![CDATA[$ 78.65]]></price>
  209. </choice>
  210. <choice>
  211. <text><![CDATA[CPM]]></text>
  212. <value><![CDATA[The Neurological Examination: Headaches & Strokes CPM]]></value>
  213. <price><![CDATA[$ 69.92]]></price>
  214. </choice>
  215. </choices>
  216. </field>
  217. <field id="42" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  218. <label><![CDATA[The Neurological Examination: Clinical Presentations]]></label>
  219. <basePrice><![CDATA[$ 0.00]]></basePrice>
  220. <choices>
  221. <choice>
  222. <text><![CDATA[Non-Member]]></text>
  223. <value><![CDATA[The Neurological Examination: Clinical Presentations Non-Member]]></value>
  224. <price><![CDATA[$ 124.63]]></price>
  225. </choice>
  226. <choice>
  227. <text><![CDATA[Member]]></text>
  228. <value><![CDATA[The Neurological Examination: Clinical Presentations Member]]></value>
  229. <price><![CDATA[$ 78.65]]></price>
  230. </choice>
  231. <choice>
  232. <text><![CDATA[CPM]]></text>
  233. <value><![CDATA[The Neurological Examination: Clinical Presentations CPM]]></value>
  234. <price><![CDATA[$ 69.92]]></price>
  235. </choice>
  236. </choices>
  237. </field>
  238. <field id="43" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  239. <label><![CDATA[Rehabilitation of the Spine]]></label>
  240. <basePrice><![CDATA[$ 0.00]]></basePrice>
  241. <choices>
  242. <choice>
  243. <text><![CDATA[Non-Member]]></text>
  244. <value><![CDATA[Rehabilitation of the Spine Non-Member]]></value>
  245. <price><![CDATA[$ 225.50]]></price>
  246. </choice>
  247. <choice>
  248. <text><![CDATA[Member]]></text>
  249. <value><![CDATA[Rehabilitation of the Spine Member]]></value>
  250. <price><![CDATA[$ 181.50]]></price>
  251. </choice>
  252. <choice>
  253. <text><![CDATA[CPM]]></text>
  254. <value><![CDATA[Rehabilitation of the Spine CPM]]></value>
  255. <price><![CDATA[$ 145.20]]></price>
  256. </choice>
  257. </choices>
  258. </field>
  259. <field id="44" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  260. <label><![CDATA[Risk Management I]]></label>
  261. <basePrice><![CDATA[$ 0.00]]></basePrice>
  262. <choices>
  263. <choice>
  264. <text><![CDATA[Non-Member]]></text>
  265. <value><![CDATA[Risk Management I Non-Member]]></value>
  266. <price><![CDATA[$ 660.00]]></price>
  267. </choice>
  268. <choice>
  269. <text><![CDATA[Member]]></text>
  270. <value><![CDATA[Risk Management I Member]]></value>
  271. <price><![CDATA[$ 181.50]]></price>
  272. </choice>
  273. <choice>
  274. <text><![CDATA[CPM]]></text>
  275. <value><![CDATA[Risk Management I CPM]]></value>
  276. <price><![CDATA[$ 145.20]]></price>
  277. </choice>
  278. </choices>
  279. </field>
  280. <field id="49" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  281. <label><![CDATA[Risk Management II]]></label>
  282. <basePrice><![CDATA[$ 0.00]]></basePrice>
  283. <choices>
  284. <choice>
  285. <text><![CDATA[Non-Member]]></text>
  286. <value><![CDATA[Risk Management II Non-Member]]></value>
  287. <price><![CDATA[$ 220.00]]></price>
  288. </choice>
  289. <choice>
  290. <text><![CDATA[Member]]></text>
  291. <value><![CDATA[Risk Management II Member]]></value>
  292. <price><![CDATA[$ 154.00]]></price>
  293. </choice>
  294. <choice>
  295. <text><![CDATA[CPM]]></text>
  296. <value><![CDATA[Risk Management II CPM]]></value>
  297. <price><![CDATA[$ 123.20]]></price>
  298. </choice>
  299. </choices>
  300. </field>
  301. <field id="45" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  302. <label><![CDATA[Risk Management III]]></label>
  303. <basePrice><![CDATA[$ 0.00]]></basePrice>
  304. <choices>
  305. <choice>
  306. <text><![CDATA[Non-Member]]></text>
  307. <value><![CDATA[Risk Management III Non-Member]]></value>
  308. <price><![CDATA[$ 121.00]]></price>
  309. </choice>
  310. </choices>
  311. </field>
  312. <field id="46" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  313. <label><![CDATA[Risk Management I, II & III]]></label>
  314. <basePrice><![CDATA[$ 0.00]]></basePrice>
  315. <choices>
  316. <choice>
  317. <text><![CDATA[Non-Member]]></text>
  318. <value><![CDATA[Risk Management I, II & III Non-Member]]></value>
  319. <price><![CDATA[$ 1,001.00]]></price>
  320. </choice>
  321. <choice>
  322. <text><![CDATA[Member]]></text>
  323. <value><![CDATA[Risk Management I, II & III Member]]></value>
  324. <price><![CDATA[$ 335.50]]></price>
  325. </choice>
  326. <choice>
  327. <text><![CDATA[CPM]]></text>
  328. <value><![CDATA[Risk Management I, II & III CPM]]></value>
  329. <price><![CDATA[$ 335.50]]></price>
  330. </choice>
  331. </choices>
  332. </field>
  333. <field id="50" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  334. <label><![CDATA[Scoliosis - An update & Spinal Stabilisation]]></label>
  335. <basePrice><![CDATA[$ 0.00]]></basePrice>
  336. <choices>
  337. <choice>
  338. <text><![CDATA[Non-Member]]></text>
  339. <value><![CDATA[Scoliosis - An update & Spinal Stabilisation Non-Member]]></value>
  340. <price><![CDATA[$ 193.60]]></price>
  341. </choice>
  342. <choice>
  343. <text><![CDATA[Member]]></text>
  344. <value><![CDATA[Scoliosis - An update & Spinal Stabilisation Member]]></value>
  345. <price><![CDATA[$ 133.10]]></price>
  346. </choice>
  347. <choice>
  348. <text><![CDATA[CPM]]></text>
  349. <value><![CDATA[Scoliosis - An update & Spinal Stabilisation CPM]]></value>
  350. <price><![CDATA[$ 117.13]]></price>
  351. </choice>
  352. </choices>
  353. </field>
  354. <field id="47" size="medium" type="product" inputType="radio" enablePrice="1" enableChoiceValue="1">
  355. <label><![CDATA[The Shoulder - A Multidisciplinary Approach]]></label>
  356. <basePrice><![CDATA[$ 0.00]]></basePrice>
  357. <choices>
  358. <choice>
  359. <text><![CDATA[Non-Member]]></text>
  360. <value><![CDATA[The Shoulder - A Multidisciplinary Approach Non-Member]]></value>
  361. <price><![CDATA[$ 124.63]]></price>
  362. </choice>
  363. <choice>
  364. <text><![CDATA[Member]]></text>
  365. <value><![CDATA[The Shoulder - A Multidisciplinary Approach Member]]></value>
  366. <price><![CDATA[$ 78.65]]></price>
  367. </choice>
  368. <choice>
  369. <text><![CDATA[CPM]]></text>
  370. <value><![CDATA[The Shoulder - A Multidisciplinary Approach CPM]]></value>
  371. <price><![CDATA[$ 62.92]]></price>
  372. </choice>
  373. </choices>
  374. </field>
  375. <field id="51" size="medium" type="html" displayOnly="1">
  376. <content><![CDATA[<script type="text/javascript">
  377. jQuery(document).ready(function() {
  378. jQuery("#resetform").click(function(){
  379. jQuery("span.ginput_total_19").html("$ 0.00");
  380. jQuery("#gform_19").get(0).reset();
  381. jQuery("#input_19_3").val("0.00");
  382. });
  383. });
  384. </script>
  385. <input type="button" value="Reset Form" id="resetform"  />]]></content>
  386. <cssClass><![CDATA[button-reset]]></cssClass>
  387. </field>
  388. <field id="3" size="medium" type="total">
  389. <label><![CDATA[Payment Total]]></label>
  390. </field>
  391. <field id="26" size="medium" type="section" displayOnly="1">
  392. <description><![CDATA[Payment is made by secure transaction and COCA does not store any credit card numbers. Once you submit this form, your credit card will be charged the above amount and you will receive a receipt via email.]]></description>
  393. <label><![CDATA[Payment]]></label>
  394. </field>
  395. <field id="21" isRequired="1" size="medium" type="text">
  396. <description><![CDATA[Please note: COCA only accepts VISA and Mastercard credit cards and Bank Debit cards.]]></description>
  397. <label><![CDATA[Card number]]></label>
  398. </field>
  399. <field id="24" isRequired="1" size="small" type="select" enableChoiceValue="1">
  400. <label><![CDATA[Expiry month]]></label>
  401. <choices>
  402. <choice>
  403. <text><![CDATA[--]]></text>
  404. <value></value>
  405. </choice>
  406. <choice>
  407. <text><![CDATA[01]]></text>
  408. <value><![CDATA[01]]></value>
  409. </choice>
  410. <choice>
  411. <text><![CDATA[02]]></text>
  412. <value><![CDATA[02]]></value>
  413. </choice>
  414. <choice>
  415. <text><![CDATA[03]]></text>
  416. <value><![CDATA[03]]></value>
  417. </choice>
  418. <choice>
  419. <text><![CDATA[04]]></text>
  420. <value><![CDATA[04]]></value>
  421. </choice>
  422. <choice>
  423. <text><![CDATA[05]]></text>
  424. <value><![CDATA[05]]></value>
  425. </choice>
  426. <choice>
  427. <text><![CDATA[06]]></text>
  428. <value><![CDATA[06]]></value>
  429. </choice>
  430. <choice>
  431. <text><![CDATA[07]]></text>
  432. <value><![CDATA[07]]></value>
  433. </choice>
  434. <choice>
  435. <text><![CDATA[08]]></text>
  436. <value><![CDATA[08]]></value>
  437. </choice>
  438. <choice>
  439. <text><![CDATA[09]]></text>
  440. <value><![CDATA[09]]></value>
  441. </choice>
  442. <choice>
  443. <text><![CDATA[10]]></text>
  444. <value><![CDATA[10]]></value>
  445. </choice>
  446. <choice>
  447. <text><![CDATA[11]]></text>
  448. <value><![CDATA[11]]></value>
  449. </choice>
  450. <choice>
  451. <text><![CDATA[12]]></text>
  452. <value><![CDATA[12]]></value>
  453. </choice>
  454. </choices>
  455. </field>
  456. <field id="25" isRequired="1" size="small" type="select" enableChoiceValue="1">
  457. <label><![CDATA[Expiry year]]></label>
  458. <choices>
  459. <choice>
  460. <text><![CDATA[--]]></text>
  461. <value></value>
  462. </choice>
  463. <choice>
  464. <text><![CDATA[2011]]></text>
  465. <value><![CDATA[11]]></value>
  466. </choice>
  467. <choice>
  468. <text><![CDATA[2012]]></text>
  469. <value><![CDATA[12]]></value>
  470. </choice>
  471. <choice>
  472. <text><![CDATA[2013]]></text>
  473. <value><![CDATA[13]]></value>
  474. </choice>
  475. <choice>
  476. <text><![CDATA[2014]]></text>
  477. <value><![CDATA[14]]></value>
  478. </choice>
  479. <choice>
  480. <text><![CDATA[2015]]></text>
  481. <value><![CDATA[15]]></value>
  482. </choice>
  483. <choice>
  484. <text><![CDATA[2016]]></text>
  485. <value><![CDATA[16]]></value>
  486. </choice>
  487. <choice>
  488. <text><![CDATA[2017]]></text>
  489. <value><![CDATA[17]]></value>
  490. </choice>
  491. <choice>
  492. <text><![CDATA[2018]]></text>
  493. <value><![CDATA[18]]></value>
  494. </choice>
  495. <choice>
  496. <text><![CDATA[2019]]></text>
  497. <value><![CDATA[19]]></value>
  498. </choice>
  499. <choice>
  500. <text><![CDATA[2020]]></text>
  501. <value><![CDATA[20]]></value>
  502. </choice>
  503. </choices>
  504. </field>
  505. <field id="23" isRequired="1" size="small" type="text">
  506. <label><![CDATA[Cvv]]></label>
  507. </field>
  508. </fields>
  509. <notification>
  510. <to><![CDATA[[email protected]]]></to>
  511. <subject><![CDATA[New submission from {form_title}]]></subject>
  512. <message><![CDATA[{all_fields}]]></message>
  513. <from><![CDATA[[email protected]]]></from>
  514. <fromName><![CDATA[Kristine Riekstins]]></fromName>
  515. </notification>
  516. <autoResponder>
  517. <toField><![CDATA[17]]></toField>
  518. <from><![CDATA[[email protected]]]></from>
  519. <subject><![CDATA[ Receipt for COCA {form_title}]]></subject>
  520. <message><![CDATA[{all_fields}]]></message>
  521. </autoResponder>
  522. <descriptionPlacement><![CDATA[below]]></descriptionPlacement>
  523. </form>
  524. </forms>
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