{"id":1148,"date":"2024-04-28T08:14:41","date_gmt":"2024-04-28T08:14:41","guid":{"rendered":"https:\/\/geripalmd.org\/staging\/4532\/?page_id=1148"},"modified":"2024-04-28T08:42:07","modified_gmt":"2024-04-28T08:42:07","slug":"online-payment","status":"publish","type":"page","link":"https:\/\/geripalmd.org\/staging\/4532\/online-payment\/","title":{"rendered":"Online Payment"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1148\" class=\"elementor elementor-1148\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2cf0eac e-con-full mavis-payment-form e-flex e-con e-parent\" data-id=\"2cf0eac\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-ce1cb75 elementor-widget elementor-widget-shortcode\" data-id=\"ce1cb75\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1158-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1158\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/staging\/4532\/wp-json\/wp\/v2\/pages\/1148#wpcf7-f1158-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1158\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1158-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/fieldset>\n<div class=\"online-payment-area ptb-120\">\n\t<div class=\"container\">\n\t\t<div class=\"online-payment-form\">\n\t\t\t<div class=\"content\">\n\t\t\t\t<h3>GeriPal-MD Payment\n\t\t\t\t<\/h3>\n\t\t\t<\/div>\n\t\t\t<div class=\"row justify-content-center align-items-center\">\n\t\t\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t\t\t<h3>GeriPal-MD Account Information\n\t\t\t\t\t<\/h3>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Memo *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"memo\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Memo\" value=\"\" type=\"text\" name=\"memo\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Upload Memo<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-memo\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file form-control\" accept=\"audio\/*,video\/*,image\/*\" aria-invalid=\"false\" type=\"file\" name=\"file-memo\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t\t\t<h3>Extra Information\n\t\t\t\t\t<\/h3>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>First Name *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your first name\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Last Name *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Your last name\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Address 1*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"address-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Address\" value=\"\" type=\"text\" name=\"address-1\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>City<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"city\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text form-control\" aria-invalid=\"false\" placeholder=\"Enter your city\" value=\"\" type=\"text\" name=\"city\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-3 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>State<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"state\"><select class=\"wpcf7-form-control wpcf7-select form-select form-control\" aria-invalid=\"false\" name=\"state\"><option value=\"Please Select\">Please Select<\/option><option value=\"Minnesota\">Minnesota<\/option><option value=\"Washington\">Washington<\/option><option value=\"Wisconsin\">Wisconsin<\/option><option value=\"New Jersey\">New Jersey<\/option><option value=\"Colorado\">Colorado<\/option><\/select><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-3 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Country<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"country\"><select class=\"wpcf7-form-control wpcf7-select form-select form-control\" aria-invalid=\"false\" name=\"country\"><option value=\"Please Select\">Please Select<\/option><option value=\"United States\">United States<\/option><option value=\"Canada\">Canada<\/option><option value=\"Norway\">Norway<\/option><option value=\"Sweden\">Sweden<\/option><option value=\"Denmark\">Denmark<\/option><\/select><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Zip Code *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"zip-code\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"12345\" value=\"\" type=\"text\" name=\"zip-code\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Email Address *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Enter your email\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-6 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Phone Number<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel form-control\" aria-invalid=\"false\" placeholder=\"Your phone number\" value=\"\" type=\"tel\" name=\"number\" \/><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><label>Description *<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"description\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Write your description\" name=\"description\"><\/textarea><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t\t\t<div class=\"form-group\">\n\t\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"gdpr\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"gdpr\" value=\"1\" class=\"gdpr-term\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">I accept all <a href=\"https:\/\/geripalmd.org\/staging\/4532\/terms-conditions\/\">terms & conditions<\/a>.<\/span><\/label><\/span><\/span><\/span>\n\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"col-lg-12 col-md-12\">\n\t\t\t\t\t<p><button type=\"submit\" class=\"default-btn\"><br \/>\n<span class=\"btn-left-i\"><br \/>\n<i class=\"flaticon-right-arrow\"><\/i><br \/>\n<\/span><br \/>\nProceed Card<br \/>\n<span class=\"btn-right-i\"><br \/>\n<i class=\"flaticon-right-arrow\"><\/i><br \/>\n<\/span><br \/>\n<\/button>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":0,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"nf_dc_page":"","footnotes":""},"class_list":["post-1148","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/pages\/1148","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/types\/page"}],"replies":[{"embeddable":true,"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/comments?post=1148"}],"version-history":[{"count":13,"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/pages\/1148\/revisions"}],"predecessor-version":[{"id":1172,"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/pages\/1148\/revisions\/1172"}],"wp:attachment":[{"href":"https:\/\/geripalmd.org\/staging\/4532\/wp-json\/wp\/v2\/media?parent=1148"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}