{"id":1126,"date":"2023-04-17T12:49:24","date_gmt":"2023-04-17T12:49:24","guid":{"rendered":"https:\/\/www.teletherapeuticsinc.com\/demo\/?page_id=1126"},"modified":"2023-04-17T12:52:00","modified_gmt":"2023-04-17T12:52:00","slug":"pay-now","status":"publish","type":"page","link":"https:\/\/www.teletherapeuticsinc.com\/demo\/pay-now\/","title":{"rendered":"Pay Now"},"content":{"rendered":"<section class=\"wpb-content-wrapper\">[vc_row][vc_column width=&#8221;1\/4&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text]<form method=\"post\" id=\"payment-form\" style=\"\n    max-width: 550px;\n    margin: 80px auto;\n\">\n\t<div id=\"paymentResponse\"><\/div>\n    <div class=\"form-row\">\n    \t<divc class=\"inline-flex\">\n\t    \t<div class=\"wpfs-form-group wfps-xp-20\">\n\t    \t\t<label>Amount<\/label>\n\t        \t<div class=\"wpfs-input-group\">\n\t\t\t\t\t<div class=\"wpfs-input-group-prepend\">\n\t\t\t\t\t\t<span class=\"wpfs-input-group-text\">$<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input name=\"custom_amount\" type=\"text\" class=\"wpfs-input-group-form-control\" \/>\n\t\t\t\t<\/div>\n\t        <\/div>\n\t\t\t\n\t\t\t<div class=\"wpfs-form-group\">\n\t\t    \t<label class=\"wpfs-form-label\" for=\"patient_name\">Bill number<\/label>\n\t\t        <input id=\"bill_number\" name=\"bill_number\" type=\"number\" oninput=\"javascript: if (this.value.length > this.maxLength) this.value = this.value.slice(0, this.maxLength);\"\n         class=\"wpfs-form-control\" maxlength=\"12\" \/>\n\t\t    <\/div>\n\t    <\/divc>\n\n        <div class=\"wpfs-form-group\">\n\t    \t<label class=\"wpfs-form-label\" for=\"patient_name\">Patient Name<\/label>\n\t        <input id=\"patient_name_1\" name=\"patient_name\" type=\"text\" class=\"wpfs-form-control\" \/>\n\t    <\/div>\n\n\t    <div class=\"wpfs-form-group\">\n\t    \t<label class=\"wpfs-form-label\" for=\"patient_name\">E-mail Address<\/label>\n\t        <input id=\"patient_email\" name=\"patient_email\" type=\"email\" class=\"wpfs-form-control\" \/>\n\t    <\/div>\n\n\t    <div class=\"wpfs-form-group\">\n\t    \t<label class=\"wpfs-form-label\" for=\"patient_name\">Pay Type<\/label>\n\t        <select id=\"pay_type\" name=\"pay_type\" class=\"wpfs-form-control\">\n\t        \t<option value=\"\">--- Select ---<\/option>\n\t        \t<option value=\"Invoice\">Invoice<\/option>\n\t        \t<option value=\"Copay\">Copay<\/option>\n\t        <\/select>\n\t    <\/div>\n\t    <div class=\"wpfs-form-group Invoice select_field\" style=\"display: none;\">\n\t    \t<label class=\"wpfs-form-label\" for=\"invoice_number\">Invoice Number<\/label>\n\t        <input id=\"invoice_number\" name=\"invoice_number\" type=\"text\" class=\"wpfs-form-control\" \/>\n\t    <\/div>\n\t    \n\t    <div class=\"wpfs-form-group Copay select_field\"  style=\"display: none;\">\n\t\t\t<label class=\"wpfs-form-label inline-label\">\n\t\t\t\t<span>Date Of Service<\/span>\n\t\t\t\t<a href=\"javascript:void(0);\" class=\"add-field-date\">Add Date<\/a>\n\t\t\t<\/label>\n\t\t\t<div class=\"fields-row\">\n\t\t\t\t<div class=\"field_date\">\n\t\t\t\t\t<input id=\"service_date\" name=\"service_date[]\" type=\"date\" class=\"wpfs-form-control wpfs-w-55\" \/>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n    \t\n    \t<div class=\"wpfs-form-group\">\n\t    \t<label class=\"wpfs-form-label\" for=\"patient_name\">Cardholder Name<\/label>\n\t        <input id=\"card_holder_name\" name=\"card_holder_name\" type=\"text\" class=\"wpfs-form-control\" \/>\n\t    <\/div>\n\n        <div class=\"wpfs-form-group\">\n\t\t\t<label class=\"wpfs-form-label\">Credit Card Number<\/label>\n\t\t\t<div id=\"card_number\" class=\"wpfs-form-control\"><\/div>\n\t\t<\/div>\n\n\t\t<div class=\"wpfs-form-group inline-flex\">\n\t\t\t<div class=\"wpfs-form-group\">\n\t\t\t\t<label class=\"wpfs-form-label\">Expiry Date<\/label>\n\t\t\t\t<div id=\"card_expiry\" class=\"wpfs-form-control\"><\/div>\n\t\t\t<\/div>\n\n\t\t\t<div class=\"wpfs-form-group\">\n\t\t\t\t<label class=\"wpfs-form-label\">CVC Code<\/label>\n\t\t\t\t<div id=\"card_cvc\" class=\"wpfs-form-control\"><\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n        <div id=\"card-errors\" role=\"alert\"><\/div>\n    <\/div>\n\n    <div class=\"form-actions\">\n\t    <button style=\"submit\" class=\"wpfs-btn wpfs-btn-primary ld-ext-right\">\n\t    \t<span>Make Payment<\/span>\n\t    \t<div class=\"ld ld-ring ld-spin\" style=\"color:#fff\"><\/div>\n\t    <\/button>\n\t<\/div>\n<\/form>\t\t\n<div id=\"paymentResponseData\"><\/div><script>\n\tvar PUBLISHABLE_KEY = 'pk_test_OLIy6maJnozFF26cAl0ZnIMB';\n<\/script>[\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/4&#8243;][\/vc_column][\/vc_row]\n<\/section>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column width=&#8221;1\/4&#8243;][\/vc_column][vc_column width=&#8221;1\/2&#8243;][vc_column_text][\/vc_column_text][\/vc_column][vc_column width=&#8221;1\/4&#8243;][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1126","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/pages\/1126","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/comments?post=1126"}],"version-history":[{"count":3,"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/pages\/1126\/revisions"}],"predecessor-version":[{"id":1129,"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/pages\/1126\/revisions\/1129"}],"wp:attachment":[{"href":"https:\/\/www.teletherapeuticsinc.com\/demo\/wp-json\/wp\/v2\/media?parent=1126"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}