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p.faq-question.ui-state-default{background-color:#fff;-webkit-transition:background .1s;-moz-transition:background .1s;-o-transition:background .1s;transition:background .1s ease}.faq-group p.faq-question.ui-state-default:hover{cursor:pointer}.faq-group p.faq-question:hover .ui-accordion-header-icon:after{color:#fff}.faq-group p.faq-question.ui-state-focus{border:0;outline:0}.faq-group p.faq-question.ui-state-active{border:0;outline:0;font-family:CentraleSans-Bold,sans-serif;font-weight:700;background-color:#1d75a2;color:#fff}.faq-group p.faq-question.ui-state-default .ui-accordion-header-icon:after{font-family:'Font Awesome 5 Free';content:"\f067";font-size:1.6rem;font-weight:900;color:#1d75a2;padding:0;margin:0 12px 0 0;position:relative;right:0;width:30px;height:30px}.faq-group p.faq-question.ui-state-active 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.gfield_description{padding-top:0}.gform_wrapper .gfield_required{color:#ff0;margin-left:4px}ul.gfield_checkbox{margin:0;list-style-type:none}ul.gfield_checkbox li{display:-webkit-box;display:-moz-box;display:-ms-flexbox;display:-webkit-flex;display:flex;align-items:flex-start;justify-content:space-between}ul.gfield_checkbox li>input{height:30px;margin-right:6px}#field_1_20{margin-bottom:10px}#field_1_10{margin-top:15px;padding-bottom:0}#field_1_8,#field_1_9{padding-bottom:15px;border-bottom:1px solid rgba(255,255,255,.18)}#field_1_8 p,#field_1_9 p{font-size:calc( 1.8rem*.9 )}#input_1_10{display:block;padding-left:0;margin:0 auto;width:100%;max-width:390px;display:-webkit-box;display:-moz-box;display:-ms-flexbox;display:-webkit-flex;display:flex;align-items:flex-start;justify-content:space-between}#input_1_10 li input[type=radio]{vertical-align:middle;display:none}#input_1_10 li input[type=radio]+label:before{color:#fff;font-family:'Font Awesome 5 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.footer-columns ul{list-style-type:none;margin:0;padding:0}footer .footer-columns ul li{text-align:left;line-height:1.2;margin-bottom:1em}footer .footer-columns ul li.title{margin-bottom:1.5em}footer .footer-columns ul li.title a{font-size:2rem;line-height:1.2;font-family:CentraleSans-Bold,sans-serif;font-weight:700}footer .footer-columns ul li a{font-size:calc( 1.8rem*.8);text-align:left;color:#fff;text-decoration:none}footer .footer-columns .row-block{padding-right:20px}ul.social-icons{width:100%;list-style-type:none;margin:0;padding:0;justify-content:center}ul.social-icons li{width:40px;height:40px;border-radius:20px;text-align:center;margin:10px}ul.social-icons li a{display:inline-block;background-color:transparent;width:40px;height:40px;-webkit-transition:.25s;-moz-transition:.25s;-ms-transition:.25s;-o-transition:.25s;transition:all .25s}ul.social-icons li a span{color:#fff;font-size:150%;margin:6px 0 0}#subscribe-form{border-bottom:1px solid rgba(255,255,255,.18);border-bottom:10px solid rgba(15,38,98,.2);padding-bottom:0;width:100%;max-width:100%}#subscribe-form .inner-wrapper{padding:0}#subscribe-form .newsletter-form{width:100%;max-width:800px;margin-left:auto;margin-right:auto;margin-bottom:70px}#subscribe-form .newsletter-form .h3{color:#fff}#subscribe-form .newsletter-form form>div.flex{flex-wrap:wrap;justify-content:space-between}#subscribe-form .newsletter-form form>div.flex>div{text-align:left}#subscribe-form .newsletter-form form>div.flex>div label{font-size:1.5rem;margin-bottom:8px;display:inline-block}#subscribe-form .newsletter-form form>div.flex>div:first-child,#subscribe-form .newsletter-form form>div.flex>div:nth-child(2){width:48%}#subscribe-form .newsletter-form form>div.flex>div:nth-child(3){width:100%;padding:20px 0;text-align:center}#subscribe-form .newsletter-form input[type=checkbox]{border:none!important;margin-right:10px}@media only screen and (min-width:1400px){.hero{-webkit-background-size:cover;-moz-background-size:cover;-o-background-size:cover;background-size:cover}}@media only screen and (max-width:1200px){header section{padding:0 30px}}@media only screen and (max-width:1090px){.hero{background-position:55% 0}header section nav .menu>li>a{padding:15px}header>section>nav{display:none}.mobile-menu-icon{display:block;margin-left:25px}.search-form{max-width:250px;margin-left:auto;margin-right:0}section.flex>div.menu-language-nav-container{margin-left:5px}}@media only screen and (max-width:980px){.row-items-4{max-width:600px;margin-left:auto;margin-right:auto}.row-items-4 .row-block{width:47%;max-width:260px;margin-right:6%;margin-bottom:6%;flex:auto}.row-items-4 .row-block:nth-child(2),.row-items-4 .row-block:nth-child(4){margin-right:0}.row-items-4 .row-block:nth-child(3),.row-items-4 .row-block:nth-child(4){margin-bottom:0}}@media only screen and (max-width:900px){.hero .hero-inner 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.h4.cta-phone{margin-right:calc(25px + 2%)}.row-items-4{display:block}.row-items-4 .row-block{width:100%;margin-bottom:12%;margin-left:auto;margin-right:auto}.row-items-4 .row-block:nth-child(n+5){margin-top:0}.row-items-4 .row-block:nth-child(2),.row-items-4 .row-block:nth-child(4){margin-left:auto;margin-right:auto}.row-items-4 .row-block:nth-child(3){margin-bottom:15%;margin-left:auto;margin-right:auto}.row-items-4 .row-block:nth-child(4){margin-bottom:15%}header .search-form{display:none}#mobile-nav ul{padding-top:20px}#mobile-nav .search-form{display:block}.mobile-menu-icon{margin-left:auto;margin-right:0}body section.flex>.maple-leaf+div.menu-language-nav-container{margin-left:10px}section.flex>div.menu-language-nav-container{margin-left:auto;margin-right:0}#subscribe-form .newsletter-form form>div.flex{display:block}#subscribe-form .newsletter-form form>div.flex>div:first-child{width:100%;margin-bottom:20px}#subscribe-form .newsletter-form 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menu-item-has-children menu-item-7789"><a href="https://www.lifeline.ca/en/healthcare/">Professionals<span><span class="line"></span></span></a> <ul class="sub-menu"> <li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-7786"><a href="https://www.lifeline.ca/en/healthcare/">Healthcare Professionals<span><span class="line"></span></span></a></li> <li class="menu-item menu-item-type-post_type menu-item-object-page menu-item-979"><a href="https://www.lifeline.ca/en/senior-living-solutions/">Senior Living Solutions<span><span class="line"></span></span></a></li> </ul> </li> </ul></div> </div> <main role="main"> <section id="hero" class="hero-test hero" style="background-image:url('https://www.lifeline.ca/wp-content/uploads/Female-Lifelnie-Referral-Consultant-with-Male-Senior.jpg')"> <div class="hero-inner"> <div class="hero-half"> <h1><strong>Medical Alert Assessment</strong></h1> <p>Find out if it’s the right time to consider a Medical Alert System</p> </div> 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class="gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_3" ><label class='gfield_label gform-field-label' for='input_1_3'>Message</label><div class='ginput_container ginput_container_textarea'><textarea name='input_3' id='input_1_3' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></li></ul> </div> <div class='gform_page_footer top_label'> <input type='button' id='gform_next_button_1_4' class='gform_next_button gform-theme-button button' value='Next' onclick='jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } ' /> </div> </div> <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-4' style='display:none;'> <div class='gform_page_fields'> <ul id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id="field_1_21" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_21" ><p class="h3"><strong>Send Us a Message</strong></p></li><li id="field_1_9" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_9" ><p style="text-align:center;margin:0;">Step 2 of 2</p></li><li id="field_1_12" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_12" ><p class="form-section-title">Contact Info</p></li><li id="field_1_5" class="gfield gfield--type-text gfield--input-type-text field-icon-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_5" ><label class='gfield_label gform-field-label' for='input_1_5'>Full Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_1_5' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_6" class="gfield gfield--type-phone gfield--input-type-phone field-icon-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_6" ><label class='gfield_label gform-field-label' for='input_1_6'>Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='medium' placeholder='###-###-####' aria-required="true" aria-invalid="false" aria-describedby="gfield_description_1_6" /></div><div class='gfield_description' id='gfield_description_1_6'>Enter your number in the following format: (###) ###-####</div></li><li id="field_1_7" class="gfield gfield--type-email gfield--input-type-email field-icon-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_7" ><label class='gfield_label gform-field-label' for='input_1_7'>Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_7' id='input_1_7' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_13" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_13" ><p class="form-section-title">Subscriber Info</p></li><li id="field_1_14" class="gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_14" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Same as contact info?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_14'><li class='gchoice gchoice_1_14_1'> <input class='gfield-choice-input' name='input_14.1' type='checkbox' value='Same as Contact Info?' id='choice_1_14_1' /> <label for='choice_1_14_1' id='label_1_14_1' class='gform-field-label gform-field-label--type-inline'>Same as Contact Info?</label> </li></ul></div></li><li id="field_1_15" class="gfield gfield--type-text gfield--input-type-text field-icon-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_15" ><label class='gfield_label gform-field-label' for='input_1_15'>Full Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_1_15' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_16" class="gfield gfield--type-phone gfield--input-type-phone field-icon-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_16" ><label class='gfield_label gform-field-label' for='input_1_16'>Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_16' id='input_1_16' type='tel' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_1_17" class="gfield gfield--type-email gfield--input-type-email field-icon-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_17" ><label class='gfield_label gform-field-label' for='input_1_17'>Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_17' id='input_1_17' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li></ul></fieldset><ul class="gform_fields top_label form_sublabel_below description_below validation_below"><li id="field_1_19" class="gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_1_19" ><p class="small">The information you provide here is used only by Lifeline. It is never sold to or shared with third parties.</p></li></ul></fieldset></div> <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /> <input type="submit" id="gform_submit_button_1" class="gform_button button" value="Contact Us" onclick="if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} pushToDataLayer(1, '1 - Contact us [MULTI-STEP - Conditional] (ENGLISH)');" onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }'> <input type='hidden' name='gform_ajax' value='form_id=1&title=&description=&tabindex=0&theme=legacy' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJbXSIsIjg3YmY3YjM0OTdlZmM3NDU4YzU0YmQyZjM5OWNkZDkxIl0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> </div></div> </form> </div> <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_1' id='gform_ajax_frame_1' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'></iframe> <script type="text/javascript"> /* <![CDATA[ */ gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https://www.lifeline.ca/wp-content/plugins/gravityforms/images/spinner.svg', true );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { /* delay the scroll by 50 milliseconds to fix a bug in chrome */ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https://www.lifeline.ca/wp-content/plugins/gravityforms/images/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger("gform_pre_post_render", [{ formId: "1", currentPage: "current_page", abort: function() { this.preventDefault(); } }]); if (event && event.defaultPrevented) { return; } const gformWrapperDiv = document.getElementById( "gform_wrapper_1" ); if ( gformWrapperDiv ) { const visibilitySpan = document.createElement( "span" ); visibilitySpan.id = "gform_visibility_test_1"; gformWrapperDiv.insertAdjacentElement( "afterend", visibilitySpan ); } const visibilityTestDiv = document.getElementById( "gform_visibility_test_1" ); let postRenderFired = false; function triggerPostRender() { if ( postRenderFired ) { return; } postRenderFired = true; jQuery( document ).trigger( 'gform_post_render', [1, current_page] ); gform.utils.trigger( { event: 'gform/postRender', native: false, data: { formId: 1, currentPage: current_page } } ); if ( visibilityTestDiv ) { visibilityTestDiv.parentNode.removeChild( visibilityTestDiv ); } } function debounce( func, wait, immediate ) { var timeout; return function() { var context = this, args = arguments; var later = function() { timeout = null; if ( !immediate ) func.apply( context, args ); }; var callNow = immediate && !timeout; clearTimeout( timeout ); timeout = setTimeout( later, wait ); if ( callNow ) func.apply( context, args ); }; } const debouncedTriggerPostRender = debounce( function() { triggerPostRender(); }, 200 ); if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) { const observer = new MutationObserver( ( mutations ) => { mutations.forEach( ( mutation ) => { if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) { debouncedTriggerPostRender(); observer.disconnect(); } }); }); observer.observe( document.body, { attributes: true, childList: false, subtree: true, attributeFilter: [ 'style', 'class' ], }); } else { triggerPostRender(); } } );} ); /* ]]> */ </script> <div class='gf_browser_chrome gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_40' style='display:none'><style></style><div id='gf_40' class='gform_anchor' tabindex='-1'></div><form method='post' enctype='multipart/form-data' target='gform_ajax_frame_40' id='gform_40' action='/en/resources/medical-alert-assessment/#gf_40' data-formid='40' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LfNyikpAAAAAGo93ZY4E0cr56tnDCJz4bQbZH7N' data-tabindex='0'><input id="input_8f433423e80fb1f8de61e6b877ec8ef9" class="gfield_recaptcha_response" type="hidden" name="input_8f433423e80fb1f8de61e6b877ec8ef9" value=""/></div> <div class='gform-body gform_body'><div id='gform_page_40_1' class='gform_page ' data-js='page-field-id-1' > <div class='gform_page_fields'><fieldset class="gfieldset gform_fieldset_begin gform_fieldset "><ul class="gform_fields top_label form_sublabel_below description_below validation_below"><li id="field_40_20" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_20" ><p class="h3"><strong>Send Us a Message</strong></p></li><li id="field_40_8" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_8" ><p style="text-align:center;margin:0;">Step 1 of 2</p></li><li id="field_40_10" class="gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_10" ><label class='gfield_label gform-field-label' >How can we help you today?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_40_10'> <li class='gchoice gchoice_40_10_0'> <input name='input_10' type='radio' value='interested in services' id='choice_40_10_0' /> <label for='choice_40_10_0' id='label_40_10_0' class='gform-field-label gform-field-label--type-inline'>I'm interested in Lifeline products & services</label> </li> <li class='gchoice gchoice_40_10_1'> <input name='input_10' type='radio' value='existing customer' id='choice_40_10_1' /> <label for='choice_40_10_1' id='label_40_10_1' class='gform-field-label gform-field-label--type-inline'>I'm a Lifeline customer in need of support</label> </li></ul></div></li><li id="field_40_1" class="gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_1" ><label class='gfield_label gform-field-label' for='input_40_1'>The Lifeline service is for<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_40_1' class='medium gfield_select' aria-required="true" aria-invalid="false" ><option value='' >Select</option><option value='For myself' >For myself</option><option value='For a relative or friend' >For a relative or friend</option><option value='For a patient or client' >For a patient or client</option></select></div></li><li id="field_40_2" class="gfield gfield--type-text field-icon-postal gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_2" ><label class='gfield_label gform-field-label' for='input_40_2'>Postal code where service is needed<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_2' id='input_40_2' type='text' value='' class='medium' aria-describedby="gfield_description_40_2" aria-required="true" aria-invalid="false" /> </div><div class='gfield_description' id='gfield_description_40_2'>This allows us to look up your local Lifeline program, in order to see which services are available to you. </div></li><li id="field_40_26" class="gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_26" ><label class='gfield_label gform-field-label' for='input_40_26'>How may we help you today?</label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_40_26' class='large gfield_select' aria-invalid="false" ><option value='Please choose one of the following' >Please choose one of the following</option><option value='I need help with billing and payments' >I need help with billing and payments</option><option value='I want to cancel the Lifeline service' >I want to cancel the Lifeline service</option><option value='I need to update my information' >I need to update my information</option><option value='I have question about my equipment or service' >I have question about my equipment or service</option><option value='I need to follow up or change my appointment' >I need to follow up or change my appointment</option></select></div></li><li id="field_40_11" class="gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_11" ><label class='gfield_label gform-field-label' for='input_40_11'>Message for Customer Support<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_40_11' class='textarea medium' aria-required="true" aria-invalid="false" rows='10' cols='50'></textarea></div></li><li id="field_40_3" class="gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_3" ><label class='gfield_label gform-field-label' for='input_40_3'>Message</label><div class='ginput_container ginput_container_textarea'><textarea name='input_3' id='input_40_3' class='textarea medium' aria-invalid="false" rows='10' cols='50'></textarea></div></li></ul> </div> <div class='gform_page_footer top_label'> <input type='button' id='gform_next_button_40_4' class='gform_next_button gform-theme-button button' value='Next' onclick='jQuery("#gform_target_page_number_40").val("2"); jQuery("#gform_40").trigger("submit",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_40").val("2"); jQuery("#gform_40").trigger("submit",[true]); } ' /> </div> </div> <div id='gform_page_40_2' class='gform_page' data-js='page-field-id-4' style='display:none;'> <div class='gform_page_fields'> <ul id='gform_fields_40_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id="field_40_21" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_21" ><p class="h3"><strong>Send Us a Message</strong></p></li><li id="field_40_9" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_9" ><p style="text-align:center;margin:0;">Step 2 of 2</p></li><li id="field_40_12" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_12" ><p class="form-section-title">Contact Info</p></li><li id="field_40_5" class="gfield gfield--type-text field-icon-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_5" ><label class='gfield_label gform-field-label' for='input_40_5'>Full Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_40_5' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_40_6" class="gfield gfield--type-phone field-icon-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_6" ><label class='gfield_label gform-field-label' for='input_40_6'>Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_40_6' type='tel' value='' class='medium' placeholder='###-###-####' aria-required="true" aria-invalid="false" aria-describedby="gfield_description_40_6" /></div><div class='gfield_description' id='gfield_description_40_6'>Enter your number in the following format: (###) ###-####</div></li><li id="field_40_7" class="gfield gfield--type-email field-icon-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_7" ><label class='gfield_label gform-field-label' for='input_40_7'>Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_7' id='input_40_7' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_40_13" class="gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_13" ><p class="form-section-title">Subscriber Info</p></li><li id="field_40_14" class="gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible" data-js-reload="field_40_14" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Same as contact info?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_40_14'><li class='gchoice gchoice_40_14_1'> <input class='gfield-choice-input' name='input_14.1' type='checkbox' value='Same as Contact Info?' id='choice_40_14_1' /> <label for='choice_40_14_1' id='label_40_14_1' class='gform-field-label gform-field-label--type-inline'>Same as Contact Info?</label> </li></ul></div></li><li id="field_40_15" class="gfield gfield--type-text field-icon-name gfield_contains_required field_sublabel_below 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