74 lines
2.6 KiB
Smarty
74 lines
2.6 KiB
Smarty
<!-- hidden things for promotional tracking -->
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<div class="visually-hidden" aria-hidden="true">
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{{{ SESSpromoid }}}
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{{{ SESSpromotion_description }}}
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{{{ SESScoupon_code }}}
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</div>
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<div class="step-1-extras">
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<p class="consumer-primary fw-bold">1. Subscriber Information</p>
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<p>Please enter the information for the person who will be using the Lifeline service.</p>
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<p class="consumer-primary fw-bold">Subscriber (Person using the service)</p>
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{{{ subscriber_first_name }}}
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{{{ subscriber_last_name }}}
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<hr />
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{{{ subscriber_gender }}}
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{{{ subscriber_birthdate }}}
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<p class="consumer-primary fw-bold pt-4">Subscriber Contact Information</p>
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{{{ subscriber_address_1 }}}
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<div class="row">
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<div class="col">
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{{{ subscriber_address_2 }}}
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</div>
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<div class="col">
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{{{ subscriber_zip }}}
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</div>
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</div>
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<div class="row">
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<div class="col">
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{{{ subscriber_city }}}
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</div>
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<div class="col">
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{{{ subscriber_state }}}
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</div>
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</div>
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{{{ subscriber_email }}}
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{{{ subscriber_phone }}}
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<p class="consumer-primary fw-bold pt-4">Caregiver Information</p>
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<p>It's important to enter caregiver information so they are linked to your Lifeline service and can easily become part of your care circle within the Cares app.</p>
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<div class="d-flex justify-content-between" style="font-size: 22px; color: #505050">
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<div class="d-flex">
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<input class="mt-2 me-2" type="radio" v-model="show_caregiver_form" id="show_caregiver_form_true" value="true">
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<label for="show_caregiver_form_true">Add caregiver information</label>
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</div>
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<div class="d-flex">
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<input class="mt-2 me-2" type="radio" v-model="show_caregiver_form" id="show_caregiver_form_false" value="false">
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<label for="show_caregiver_form_false">Add caregiver information at a later time</label>
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</div>
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</div>
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<div v-show="show_caregiver_form === 'true'">
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{{{ caregiver_relation }}}
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{{{ caregiver_first_name }}}
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{{{ caregiver_last_name }}}
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{{{ caregiver_email }}}
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{{{ caregiver_phone }}}
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<div class="d-flex">
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<div class="input-wrapper">
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<input type="checkbox" v-model="caregiver_authorized_box" />
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</div>
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<div class="label-wrapper" @click="caregiver_authorized_box = !caregiver_authorized_box">
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{{{ caregiver_authorized }}}
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</div>
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</div>
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</div>
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<p class="consumer-primary fw-bold pt-4">Billing details</p>
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</div>
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