function validatePJForm(form) {
var failed = 0; for (var index in toValidate) { if (!document.querySelector(toValidate[index]).value) { failed++; document.querySelector(toValidate[index]).previousElementSibling.style.color = 'red'; } else { document.querySelector(toValidate[index]).previousElementSibling.style.color = ''; } }
var paymentReason = document.querySelector('#pjQuickShopCustomForm input[type="checkbox"]:not(#pj-patient-is-card-holder):checked');
if (!paymentReason) { failed++; var reasons = document.querySelectorAll('#pj-payment-account-balance,#pj-payment-other,#pj-payment-prepayment'); for (var el in reasons) { var label = reasons[el].nextElementSibling; if (label) label.style.color = 'red'; } }
var amount = form.price.value;
if (amount == '' || isNaN(amount)) failed++;
if (failed > 0) { document.querySelector('#pjHiddenErrorMessage').style.visibility = 'visible'; return false; }
switch(paymentReason.id) { case 'pj-payment-account-balance': form.notes.value += 'Payment on Account Balance\n'; break; case 'pj-payment-prepayment': form.notes.value += 'Pre Payment\n'; break; case 'pj-payment-other': form.notes.value += 'Other: ' + document.querySelector('#pj-payment-other-text').value.trim() + '\n'; break; }
form.notes.value += 'Patient DOB: ' + document.querySelector('#pj-patient-dob').value.trim() + '\n';
if (!document.querySelector('#pj-patient-is-card-holder').checked) { form.notes.value += 'Patient Name: ' + document.querySelector('#pj-patient-first-name').value.trim() + ' ' + document.querySelector('#pj-patient-last-name').value.trim() + '\n'; form.notes.value += 'Patient Billing Address: ' + document.querySelector('#pj-patient-street-address').value.trim() + '\n'; form.notes.value += 'City: ' + document.querySelector('#pj-patient-city').value.trim() + '\n'; form.notes.value += 'State: ' + document.querySelector('#pj-patient-state').value.trim() + '\n'; form.notes.value += 'Zip: ' + document.querySelector('#pj-patient-zip').value.trim() + '\n'; form.notes.value += 'Patient Phone: ' + document.querySelector('#pj-patient-phone').value.trim() + '\n'; form.notes.value += 'Patient Email: ' + document.querySelector('#pj-patient-email').value.trim() + '\n'; } else { form.notes.value += 'Patient is the card holder'; }
return true; } function pjPaymentReason(input) { if (input.checked) { var boxes = document.querySelectorAll('#pjQuickShopCustomForm input'); for (var x in boxes) { if (boxes[x].id == 'pj-patient-is-card-holder') continue; if (boxes[x].type == 'checkbox' && boxes[x] !== input) boxes[x].checked = false; } } }