{"id":1183,"date":"2017-04-03T11:37:08","date_gmt":"2017-04-03T11:37:08","guid":{"rendered":"https:\/\/www.medxjordan.com\/?page_id=1183"},"modified":"2023-08-24T06:49:15","modified_gmt":"2023-08-24T06:49:15","slug":"patient-registration","status":"publish","type":"page","link":"https:\/\/www.medxjordan.com\/en\/patient-registration\/","title":{"rendered":"Patient Registration"},"content":{"rendered":"<p><div class=\"registration-style\">\r\n    <div class=\"row\">\r\n        <div id=\"iv-form3\" class=\"col-md-12\">\r\n            <form autocomplete=\"off\" id=\"iv_directories_registrationrr\" name=\"iv_directories_registrationrr\" class=\"form-horizontal\" action=\"https:\/\/www.medxjordan.com\/en\/patient-registration\/?&submit_iv_directoriesregister_patient=register_patient\" method=\"post\" role=\"form\">\r\n                <input type=\"hidden\" name=\"pippin_register_new_patient_check_nonce\" value=\"f8078cc2a3\"\/>\r\n                <input type=\"hidden\" name=\"iv-submit-stripe\" id=\"iv-submit-stripe\" value=\"register\">\r\n                <input type=\"hidden\" name=\"submit_iv_directoriesregister_patient\" id=\"submit_iv_directoriesregister_patient\" value=\"register_patient\">\r\n                <div class=\"content\">\r\n                    <h3  class=\"form-title\">Patient Registration<\/h3>\r\n                    <div class=\"form-content\">\r\n                        <div class=\"row\">\r\n                            <div class=\"col-md-12\">\r\n                                                                <!--\r\n                                        For Form Validation we used plugins http:\/\/formvalidator.net\/index.html#reg-form\r\n                                        This is in line validation so you can add fields easily.\r\n                                -->\r\n                                <div>\r\n                                    <div id=\"selected-column-1\" class=\" \">\r\n                                        <div class=\"text-center\" id=\"loading\"> <\/div>\r\n                                        <div class=\"form-group row\"  >\r\n                                            <label  class=\"col-md-3 control-label\">\r\n                                                First Name                                                <span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-9\">\r\n                                                <input type=\"text\"  name=\"iv_member_fname\"  placeholder=\"Enter First Name\" value=\"\"   >\r\n                                            <\/div>\r\n                                        <\/div>\r\n                                        <div class=\"form-group row\"  >\r\n                                            <label  class=\"col-md-3 control-label\">Last Name<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-9\">\r\n                                                <input type=\"text\"  name=\"iv_member_lname\" placeholder=\"Enter Last Name\" data- value=\"\" >\r\n                                            <\/div>\r\n                                        <\/div>\r\n                                        <div class=\"form-group row\"  >\r\n                                            <label  class=\"col-md-3 control-label\">Username<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-9\">\r\n                                                <input type=\"text\"  name=\"iv_member_user_name\"   value=\"\" class=\"form-control ctrl-textbox\" placeholder=\"Enter Username\"  >\r\n                                            <\/div>\r\n                                        <\/div>\r\n                                        <div class=\"form-group row\">\r\n                                            <label  class=\"col-md-3 control-label\" >Email Address<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-9\">\r\n                                                                                                <input type=\"text\" name=\"iv_member_email\"  class=\"form-control ctrl-textbox\" placeholder=\"example@mail.com\" value=\"\" >\r\n                                            <\/div>\r\n                                            \r\n                                        <\/div>\r\n                                        <!-- add field mobile number on Patient form   -->\r\n                                        <div id=\"mobile_number\" class=\"form-group row\">\r\n                                            <label for=\"text\" class=\"col-md-3 control-label\">Mobile Number<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-9\">\r\n                                                <input type=\"hidden\" name=\"phone\" id=\"phone\" >\r\n                                                <input type=\"tel\" maxlength=\"16\" onchange=\"change_number () ;\" id=\"mobile\" class=\"form-control\" name=\"mobile\" value=\"+962\" \/>         \r\n                                                \r\n                                            <\/div>\r\n                                        <\/div>\r\n                                                                                <br\/>\r\n                                        <!-- <div >\r\n                                            <label for=\"text\" class=\"col-md-3 control-label\">Type Number<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-9\">\r\n\r\n                                                                                           <\/div>\r\n                                        <\/div> -->\r\n\t\t\t\t\t\t\t\t\t\t\r\n                                        <div class=\"form-group row\"  >\r\n                                            <label  class=\"col-md-4 control-label\">Password<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-8\">\r\n                                                <input type=\"password\"  name=\"iv_member_pass\" placeholder=\"Password\" data- value=\"\" >\r\n                                            <\/div>\r\n                                        <\/div>\r\n                                        <div class=\"form-group row\"  >\r\n                                            <label  class=\"col-md-4 control-label\">Confirm Password<span class=\"chili\"><\/span><\/label>\r\n                                            <div class=\"col-md-8\">\r\n                                                <input type=\"password\"  name=\"iv_member_confirm_pass\" placeholder=\"Confirm Password\" data- value=\"\" >\r\n                                            <\/div>\r\n                                        <\/div>\r\n\r\n                                                                            <\/div>\r\n                                <\/div>\r\n                                <input type=\"hidden\" name=\"CountryCode\" id=\"CountryCode\" value=\"\" >\r\n                                <input type=\"hidden\" name=\"hidden_form_name\" id=\"hidden_form_name\" value=\"iv_directories_registration\">\r\n                               <div class=\"form-group row \">\r\n                                    <label  class=\"col-md-12 control-label\">\r\n                                        <input type=\"checkbox\" class=\"input-checkbox\" name=\"iv_member_term\" id=\"iv_member_term\"  >\r\n                                        <span>I\u2019ve read and accept the <a href=\"https:\/\/www.medxjordan.com\/en\/terms-of-use\/\" target=\"_blank\">Terms of Use<\/a>.<\/span>\r\n                                    <\/label>        \r\n                                <\/div>\r\n                                <div class=\"row\">\r\n                                    <div class=\"col-md-3 \"> \r\n                                    <\/div>\r\n\r\n                                    <div class=\"col-md-9 \">\r\n                                        <input type=\"submit\" id=\"submit_iv_directories_payment\" name=\"submit_iv_directories_payment\"  class=\"btn-new btn-custom ctrl-btn\" value=\"Submit\" >\r\n                                    <\/div>\r\n                                <\/div>\r\n                            <\/div>\r\n                        <\/div>\r\n                    <\/div>\r\n                <\/div>\r\n                <br\/>\r\n            <\/form>\r\n            <div style=\"display: none;\">\r\n                <img src='https:\/\/www.medxjordan.com\/wp-content\/themes\/medical-directory\/framework\/hospital-doctor-directory\/admin\/files\/images\/loader.gif' \/>\r\n            <\/div>\r\n        <\/div>\r\n    <\/div>\r\n<\/div>\r\n\r\n\r\n<script type=\"text\/javascript\">\r\n\r\n\r\n jQuery ( document ).ready ( function ()\r\n    {\r\n        \/\/ vaildation mobile number must be numbers only \r\n\r\n         jQuery ( document ).on ( \"keydown\" , \"#mobile\" , function ( event )\r\n        {\r\n            var keycode = event.which ;\r\n            if ( !( event.shiftKey == false && ( keycode == 46 || \/*keycode == 107 ||*\/ keycode == 8 || keycode == 37 || keycode == 39 || ( keycode >= 48 && keycode <= 57 ) || ( keycode >= 96 && keycode <= 105 ) ) ) )\r\n            {\r\n                event.preventDefault () ;\r\n            }\r\n        } ) ;\r\n\r\n        \/\/ setTimeout ( \"change_number();\" , 100 ) ;\r\n        jQuery ( '#mobile_number' )\r\n                .find ( '[name=\"mobile\"]' )\r\n                .intlTelInput ( {\r\n                    utilsScript : 'https:\/\/www.medxjordan.com\/wp-content\/themes\/medical-directory-child\/intl-tel-input-11.0.10\/build\/js\/utils.js' ,\r\n                    autoPlaceholder : false ,\r\n                    preferredCountries : [ 'jo' ]\r\n                } ) ;\r\n    } ) ;\r\n\r\n    jQuery ( window ).load ( function ()\r\n    {\r\n        setTimeout ( \"change_number();\" , 400 ) ;\r\n        \/\/ jQuery ( '#mobile' ).val('');\r\n        \/\/ jQuery ( '.flag-container' ).css ( \"pointer-events\" , \" none\" ) ;\r\n    } ) ;\r\n\r\n    function change_country ()\r\n    {\r\n       \r\n        setTimeout ( \"change_number();\" , 300 ) ;\r\n    }\r\n\r\n  function change_number ()\r\n    {\r\n        var q   = jQuery('.selected-flag .iti-flag' ).attr('class');\r\n        var t   = q.split('iti-flag');\r\n        jQuery('#CountryCode').val(t[1].trim());\r\n        \r\n        var xxx = jQuery ( '.selected-flag' ).attr ( 'title' ) ;\r\n        xxx = xxx.split ( \"+\" ).pop () ;\r\n        xxx = \"+\" + xxx ;\r\n        jQuery ( '#phone' ).val ( xxx ) ;\r\n        jQuery ( '#mobile' ).val ( jQuery ( '#mobile' ).val ().replace ( jQuery ( '#phone' ).val (  ) , '' ) ) ;\r\n    }\r\n\r\n<\/script>\r\n<\/p>","protected":false},"excerpt":{"rendered":"Patient Registration First Name Last Name Username Email Address Mobile Number Password Confirm Password I\u2019ve read and accept the Terms of Use.","protected":false},"author":1,"featured_media":1183,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"templates\/full-width-page.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-1183","page","type-page","status-publish","has-post-thumbnail","hentry"],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/pages\/1183","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/comments?post=1183"}],"version-history":[{"count":4,"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/pages\/1183\/revisions"}],"predecessor-version":[{"id":1553,"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/pages\/1183\/revisions\/1553"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/pages\/1183"}],"wp:attachment":[{"href":"https:\/\/www.medxjordan.com\/en\/wp-json\/wp\/v2\/media?parent=1183"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}