70 lines
1.8 KiB
Smarty
70 lines
1.8 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">Subscriber Contact Information</p>
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<p>Please enter the information for the person who will be using the MedicalAlert service.</p>
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{{{ subscriber_first_name }}}
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{{{ subscriber_last_name }}}
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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">Emergency Contacts</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="checkbox" v-model="show_caregiver_form">
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<label>Add Emergency Contacts</label>
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</div>
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</div>
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<div v-show="show_caregiver_form">
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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>
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<p class="consumer-primary fw-bold pt-4">Billing Information</p>
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<div class="d-flex justify-content-between" style="font-size: 22px; color: rgb(80, 80, 80);">
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<div class="d-flex">
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<input class="mt-2 me-2" type="checkbox" id="sameAsSubscriber" name="sameAsSubscriber" onclick="copySubscriberAddress()">
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<label for="sameAsSubscriber">Billing same as Subscriber</label>
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</div>
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</div>
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</div>
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