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  1. <!DOCTYPE html>
  2. <html lang="en">
  3. <head>
  4. <meta charset="utf-8">
  5. <meta http-equiv="X-UA-Compatible" content="IE=edge">
  6. <meta name="viewport" content="width=device-width, initial-scale=1">
  7. <title>Smart Relief Rx - See if your insurance&#39;s prescription plan covers non-narcotic pain relief</title>
  8. <!-- Bootstrap -->
  9. <link href="http://smartreliefrx.com/qualify/css/bootstrap.css" rel="stylesheet">
  10. <link href="http://smartreliefrx.com/qualify/css/styles.css" rel="stylesheet">
  11. <!-- Bootstrap Validator -->
  12. <link rel="stylesheet" href="http://smartreliefrx.com/qualify/css/bootstrapValidator.css"/>
  13. <link rel="stylesheet" href="http://smartreliefrx.com/pain-relief-offer/style-second.css"/>
  14. <script src="http://smartreliefrx.com/qualify/js/jquery-2.1.0.min.js"></script>
  15.  
  16. <script>
  17. var getParamValue = (function() {
  18. var params;
  19. var resetParams = function() {
  20. var query = window.location.search;
  21. var regex = /[?&;](.+?)=([^&;]+)/g;
  22. var match;
  23.  
  24. params = {};
  25.  
  26. if (query) {
  27. while (match = regex.exec(query)) {
  28. params[match[1]] = decodeURIComponent(match[2]);
  29. }
  30. }
  31. };
  32.  
  33. window.addEventListener
  34. && window.addEventListener('popstate', resetParams);
  35.  
  36. resetParams();
  37.  
  38. return function(param) {
  39. return params.hasOwnProperty(param) ? params[param] : null;
  40. }
  41.  
  42. })();​
  43. </script>
  44.  
  45. <script>
  46. function MM_validateForm() { //v4.0
  47. if (document.getElementById){
  48. var i,p,q,nm,test,num,min,max,errors='',args=MM_validateForm.arguments;
  49. for (i=0; i<(args.length-2); i+=3) { test=args[i+2]; val=document.getElementById(args[i]);
  50. if (val) { nm=val.name; if ((val=val.value)!="") {
  51. if (test.indexOf('isEmail')!=-1) { p=val.indexOf('@');
  52. if (p<1 || p==(val.length-1)) errors+='- '+nm+' must contain an e-mail address.n';
  53. } else if (test!='R') { num = parseFloat(val);
  54. if (isNaN(val)) errors+='- '+nm+' must contain a number.n';
  55. if (test.indexOf('inRange') != -1) { p=test.indexOf(':');
  56. min=test.substring(8,p); max=test.substring(p+1);
  57. if (num<min || max<num) errors+='- '+nm+' must contain a number between '+min+' and '+max+'.n';
  58. } } } else if (test.charAt(0) == 'R') errors += '- '+nm+' is required.n'; }
  59. } if (errors) alert('The following error(s) occurred:n'+errors);
  60. document.MM_returnValue = (errors == '');
  61. } }
  62. </script>
  63. <!-- Fonts -->
  64. <link href='http://fonts.googleapis.com/css?family=Open+Sans:400,300,600,700,800' rel='stylesheet' type='text/css'>
  65. <link href='http://fonts.googleapis.com/css?family=Open+Sans+Condensed:300,300italic,700' rel='stylesheet' type='text/css'>
  66. <link href='http://fonts.googleapis.com/css?family=Lato:400,100,100italic,300,300italic,400italic,700,700italic,900,900italic' rel='stylesheet' type='text/css'>
  67. <!-- HTML5 Shim and Respond.js IE8 support of HTML5 elements and media queries -->
  68. <!-- WARNING: Respond.js doesn't work if you view the page via file:// -->
  69. <!--[if lt IE 9]>
  70. <script src="https://oss.maxcdn.com/html5shiv/3.7.2/html5shiv.min.js"></script>
  71. <script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
  72. <![endif]-->
  73. </head>
  74.  
  75. <body id="home">
  76. <noscript><center>Please enable JavaScript or use an updated browser! Thanks!</center></noscript>
  77. <div class="navbar navbar-default navbar-static-top" role="navigation">
  78. <div class="container">
  79. <div class="navbar-header">
  80. <button type="button" class="navbar-toggle" data-toggle="collapse" data-target=".navbar-collapse">
  81. <span class="sr-only">Toggle navigation</span>
  82. <span class="icon-bar"></span>
  83. <span class="icon-bar"></span>
  84. <span class="icon-bar"></span>
  85. </button>
  86. <a target="_BLANK" class="navbar-brand" href="http://smartreliefrx.com">
  87. <img src="http://smartreliefrx.com/qualify/img/logo-white-text.png" alt="" class="nav-logo"/>
  88. </a>
  89. </div>
  90. <!--<div class="navbar-collapse collapse">
  91. <ul class="nav navbar-nav navbar-right">
  92. <li><a target="_blank" href="http://smartreliefrx.com/about-cc.html">Learn About Custom Compounds</a></li>
  93. <li><a target="_blank" href="http://smartreliefrx.com/speak-to-a-doctor.html">Speak to a Doctor</a></li>
  94. <li><a target="_blank" href="http://smartreliefrx.com/getting-started/contact.html">Get Started</a></li>
  95. </ul>-->
  96. </div>
  97. </div>
  98. </div>
  99. <div class="container">
  100. <div class="row"><div style="font-weight: +20%;">
  101. <div class="col-xs-12 col-sm-offset-2 col-sm-8 col-md-offset-2 col-md-8 col-lg-offset-2 col-lg-8">
  102. <h1>You&#39;re Almost There! Only a few last questions about your Insurance Plan...</h1>
  103. </div>
  104. <div class="col-xs-12 col-sm-offset-2 col-sm-8 col-md-offset-2 col-md-8 col-lg-offset-2 col-lg-8">
  105. <h5><b>Please make sure you have your Insurance Card handy, you'll need it to complete the following questions.</b></h5>
  106. </div></div>
  107. </div>
  108. <div class="row">
  109. </div>
  110. <div class="row">
  111. <div class="col-xs-12 col-sm-offset-2 col-sm-8 col-md-offset-2 col-md-8 col-lg-offset-2 col-lg-8">
  112. <form method="POST" action="https://vanillasoft.net/web/post.aspx" name="MyForm" id="MyForm" onSubmit="if (this.email.value == '' || this.firstName.value == '') {return false;}">
  113. <div class="input-field">
  114. <select name="insuranceType" class="form-control input-lg" id="exampleInputLarge-select" onChange="window.document.location.href=this.options[this.selectedIndex].value;" value="GO" style="color:#0d5973 !important;">
  115. <option disabled alue="Please Choose an Insurance" selected>Please Choose an Insurance Type</option
  116. ><option value="http://smartreliefrx.com/qualify/not-qualified.html">Medicare</option>
  117. <option value="http://smartreliefrx.com/qualify/not-qualified.html">Medicaid</option>
  118. <option value="#">Private Insurance</option>
  119. </select>
  120. </div>
  121. <p>
  122. <input name="firstName" type="text" class="form-control form-control-name" id="firstName" placeholder="First Name" size="33" maxlength="50">
  123. </p>
  124. <p>
  125. <input name="LastName" type="text" class="form-control form-control-name" id="LastName" placeholder="Last Name" size="33" maxlength="50">
  126. </p>
  127. <p>
  128. <input name="email" type="text" class="form-control form-control-email" id="email" placeholder="Email Address" size="33" maxlength="50">
  129. </p>
  130. <p>
  131. <input name="phone" type="text" class="form-control form-control-phone" id="phone" placeholder="Phone Number" size="10">
  132. </p>
  133. <p>
  134. <input type="hidden" name="SUB_1" value="">
  135. </p>
  136. <p>
  137. <input type="hidden" name="AFFILIATE_ID" value="">
  138. </p>
  139. <p>
  140. <input name="birthdate" type="text" class="form-control form-control-name" id="birthdate" placeholder="Birthdate" size="33">
  141. </p>
  142. <p>
  143. <input name="address" type="text" class="form-control form-control-email" id="address" placeholder="Address" size="33">
  144. </p>
  145. <p>
  146. <input name="city" type="text" class="form-control form-control-phone" id="city" placeholder="City" style="margin-top: 20px!important;" size="33">
  147. </p>
  148. <div class="form-group">
  149.  
  150. <p><div class="input-field" name="state">
  151. <select value="State" name="state" class="form-control input-lg" id="exampleInputLarge-select" style="height: 40px!important; margin-top: 20px!important; color:#0d5973 !important;">
  152. <option value="">Please Choose a State:</option>
  153. <option value="Alabama">Alabama</option>
  154. <option value="Arizona">Arizona</option>
  155. <option value="California">California</option>
  156. <option value="Colorado">Colorado</option>
  157. <option value="Connecticut">Connecticut</option>
  158. <option value="Delaware">Delaware</option>
  159. <option value="District Of Columbia">District Of Columbia</option>
  160. <option value="Florida">Florida</option>
  161. <option value="Georgia">Georgia</option>
  162. <option value="Illinois">Illinois</option>
  163. <option value="Indiana">Indiana</option>
  164. <option value="Iowa">Iowa</option>
  165. <option value="Kentucky">Kentucky</option>
  166. <option value="Maine">Maine</option>
  167. <option value="Maryland">Maryland</option>
  168. <option value="Massachusetts">Massachusetts</option>
  169. <option value="Michigan">Michigan</option>
  170. <option value="Minnesota">Minnesota</option>
  171. <option value="Missouri">Missouri</option>
  172. <option value="Montana">Montana</option>
  173. <option value="Nebraska">Nebraska</option>
  174. <option value="New Hampshire">New Hampshire</option>
  175. <option value="New Jersey">New Jersey</option>
  176. <option value="New Mexico">New Mexico</option>
  177. <option value="New York">New York</option>
  178. <option value="North Carolina">North Carolina</option>
  179. <option value="North Dakota">North Dakota</option>
  180. <option value="Ohio">Ohio</option>
  181. <option value="Oklahoma">Oklahoma</option>
  182. <option value="Pennsylvania">Pennsylvania</option>
  183. <option value="Rhode Island">Rhode Island</option>
  184. <option value="South Carolina">South Carolina</option>
  185. <option value="Tennessee">Tennessee</option>
  186. <option value="Texas">Texas</option>
  187. <option value="Utah">Utah</option>
  188. <option value="Virginia">Virginia</option>
  189. <option value="Washington">Washington</option>
  190. <option value="West Virginia">West Virginia</option>
  191. <option value="Wisconsin">Wisconsin</option>
  192. </select>
  193. </div>
  194. </p>
  195.  
  196. <p>
  197. <input name="zip" type="text" class="form-control form-control-email" id="zip" placeholder="Zip Code" size="33" maxlength="5">
  198. </p>
  199. <p>
  200. <input name="insuranceComp" type="text" class="form-control form-control-phone" id="insuranceComp" placeholder="Insurance Company" size="33" maxlength="30">
  201. </p>
  202. <p>
  203. <input name="memberID" type="text" class="form-control form-control-phone" id="memberID" placeholder="Member ID or Policy Number" size="33">
  204. </p>
  205. <p>
  206. <input name="RxBin" type="text" class="form-control form-control-phone" id="RxBin" placeholder="RX BIN Number" size="33">
  207. </p>
  208. <p>
  209. <input name="PcnNumber" type="text" class="form-control form-control-phone" id="PcnNumber" placeholder="PCN Number" size="33">
  210. </p>
  211. <p>
  212. <input name="groupID" type="text" class="form-control form-control-phone" id="groupID" placeholder="RX Group Number" size="33">
  213. </p>
  214. <p>
  215. <input name="insurancePhone" type="text" class="form-control form-control-phone" id="insurancePhone" placeholder="Insurance Phone Number" maxlength="10" size="10">
  216. </p>
  217. <input type="submit" class="btn pi-btn col-xs-12 col-sm-offset-2 col-sm-8 col-md-offset-2 col-md-8 col-lg-offset-2 col-lg-8" id="" placeholder="Submit" style="background-color:#009ca8!important;color: #FFF!important;" onClick="MM_validateForm('firstName','','R','LastName','','R','email','','RisEmail','phone','','RisNum','birthdate','','R','address','','R','city','','R','zip','','RisNum','insuranceComp','','R','memberID','','R','RxBin','','R','PcnNumber','','R','groupID','','R','insurancePhone','','RisNum');return document.MM_returnValue" value="Submit">
  218. </p>
  219. </form>
  220. <script type="text/javascript" language="JavaScript">
  221. function FillForm() {
  222. // Specify form's name between the quotes on next line.
  223. var FormName = "MyForm";
  224. var questionlocation = location.href.indexOf('?');
  225. if(questionlocation < 0) { return; }
  226. var q = location.href.substr(questionlocation + 1);
  227. var list = q.split('&');
  228. for(var i = 0; i < list.length; i++) {
  229. var kv = list[i].split('=');
  230. if(! eval('document.'+FormName+'.'+kv[0])) { continue; }
  231. kv[1] = unescape(kv[1]);
  232. if(kv[1].indexOf('"') > -1) {
  233. var re = /"/g;
  234. kv[1] = kv[1].replace(re,'\"');
  235. }
  236. eval('document.'+FormName+'.'+kv[0]+'.value="'+kv[1]+'"');
  237. }
  238. }
  239. FillForm();
  240. //-->
  241. </script>
  242. </p>
  243. <p>&nbsp;
  244.  
  245. </p>
  246. <br>
  247. <br>
  248. <center>
  249. <a target="_BLANK" href="https://www.facebook.com/SmartReliefRx"><img src="http://smartreliefrx.com/diabetes/facebook.png" style="text-alignment: center!important;" width="50" style=""></a>
  250. <br>
  251.  
  252. <a target="_BLANK" href="https://www.facebook.com/SmartReliefRx" style="color: #FFF; font-size: 14px; font-family: Arial;">Find us on Facebook!</a><br/>
  253. </div>
  254. <div class="col-xs-12 col-sm-12 col-md-12 col-lg-12 text-center">
  255. <a target="_BLANK" href="http://www.smartreliefrx.com/pain-relief-offer/privacy-policy.html" style="color: #FFF; font-size: 12px; font-family: Arial;">Privacy Policy</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<a target="_BLANK"href="http://www.smartreliefrx.com/pain-relief-offer/terms.html" style="color: #FFF; font-size: 12px; font-family: Arial;">Terms and Agreement</a>
  256. <br>
  257. <br>
  258. <br>
  259. </div>
  260. <p>
  261. </div>
  262. <script src="http://smartreliefrx.com/qualify/js/jquery-2.1.0.min.js"></script>
  263. <!-- Bootstrap -->
  264. <script type="text/javascript" src="http://smartreliefrx.com/qualify/js/bootstrap.min.js"></script>
  265. <!-- Bootstrap Validator -->
  266. <script type="text/javascript" src="http://smartreliefrx.com/qualify/js/bootstrapValidator.js"></script>
  267. </body>
  268. </html>
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