portal/account/register.php

   1 <?php
   2 /**
   3  * Portal Registration Wizard
   4  *
   5  * @package OpenEMR
   6  * @link    http://www.open-emr.org
   7  * @author  Jerry Padgett <sjpadgett@gmail.com>
   8  * @copyright Copyright (c) 2017-2018 Jerry Padgett <sjpadgett@gmail.com>
   9  * @license https://www.gnu.org/licenses/agpl-3.0.en.html GNU Affero General Public License 3
  10  */
  11
  12 session_start();
  13 session_regenerate_id(true);
  14
  15 unset($_SESSION['itsme']);
  16 $_SESSION['patient_portal_onsite_two'] = true;
  17 $_SESSION['authUser'] = 'portal-user';
  18 $_SESSION['pid'] = true;
  19 $_SESSION['register'] = true;
  20
  21 $_SESSION['site_id'] = isset($_SESSION['site_id']) ? $_SESSION['site_id'] : 'default';
  22 $landingpage = "index.php?site=" . $_SESSION['site_id'];
  23
  24 $ignoreAuth_onsite_portal_two = true;
  25
  26 require_once("../../interface/globals.php");
  27
  28 $res2 = sqlStatement("select * from lang_languages where lang_description = ?", array(
  29     $GLOBALS['language_default']
  30 ));
  31 for ($iter = 0; $row = sqlFetchArray($res2); $iter ++) {
  32     $result2[$iter] = $row;
  33 }
  34 if (count($result2) == 1) {
  35     $defaultLangID = $result2[0]{"lang_id"};
  36     $defaultLangName = $result2[0]{"lang_description"};
  37 } else {
  38     // default to english if any problems
  39     $defaultLangID = 1;
  40     $defaultLangName = "English";
  41 }
  42
  43 if (! isset($_SESSION['language_choice'])) {
  44     $_SESSION['language_choice'] = $defaultLangID;
  45 }
  46 // collect languages if showing language menu
  47 if ($GLOBALS['language_menu_login']) {
  48     // sorting order of language titles depends on language translation options.
  49     $mainLangID = empty($_SESSION['language_choice']) ? '1' : $_SESSION['language_choice'];
  50     if ($mainLangID == '1' && ! empty($GLOBALS['skip_english_translation'])) {
  51         $sql = "SELECT * FROM lang_languages ORDER BY lang_description, lang_id";
  52         $res3 = SqlStatement($sql);
  53     } else {
  54         // Use and sort by the translated language name.
  55         $sql = "SELECT ll.lang_id, " . "IF(LENGTH(ld.definition),ld.definition,ll.lang_description) AS trans_lang_description, " . "ll.lang_description " .
  56              "FROM lang_languages AS ll " . "LEFT JOIN lang_constants AS lc ON lc.constant_name = ll.lang_description " .
  57              "LEFT JOIN lang_definitions AS ld ON ld.cons_id = lc.cons_id AND " . "ld.lang_id = ? " .
  58              "ORDER BY IF(LENGTH(ld.definition),ld.definition,ll.lang_description), ll.lang_id";
  59         $res3 = SqlStatement($sql, array(
  60             $mainLangID
  61         ));
  62     }
  63
  64     for ($iter = 0; $row = sqlFetchArray($res3); $iter ++) {
  65         $result3[$iter] = $row;
  66     }
  67
  68     if (count($result3) == 1) {
  69         // default to english if only return one language
  70         $hiddenLanguageField = "<input type='hidden' name='languageChoice' value='1' />\n";
  71     }
  72 } else {
  73     $hiddenLanguageField = "<input type='hidden' name='languageChoice' value='" . htmlspecialchars($defaultLangID, ENT_QUOTES) . "' />\n";
  74 }
  75
  76 ?>
  77 <!DOCTYPE html>
  78 <html>
  79 <head>
  80 <title><?php echo xlt('New Patient'); ?> | <?php echo xlt('Register'); ?></title>
  81 <meta content='width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no' name='viewport'>
  82 <meta name="description" content="Developed By sjpadgett@gmail.com">
  83
  84 <link href="<?php echo $GLOBALS['assets_static_relative']; ?>/font-awesome-4-6-3/css/font-awesome.min.css" rel="stylesheet" type="text/css" />
  85 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.min.css">
  86 <link href="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap-3-3-4/dist/css/bootstrap.min.css" rel="stylesheet" type="text/css" />
  87 <link href="./../assets/css/register.css" rel="stylesheet" type="text/css" />
  88
  89 <script src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-3-1-1/index.js" type="text/javascript"></script>
  90
  91 <script src="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap-3-3-4/dist/js/bootstrap.min.js" type="text/javascript"></script>
  92 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker-2-5-4/build/jquery.datetimepicker.full.min.js"></script>
  93 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/emodal-1-2-65/dist/eModal.js"></script>
  94
  95 <script>
  96 var newPid = 0;
  97 var curPid = 0;
  98 var provider = 0;
  99
 100 $(document).ready(function () {
 101     /* // test data
 102     $("#emailInput").val("me@me.com");
 103     $("#fname").val("Jerry");
 104     $("#lname").val("Padgett");
 105     $("#dob").val("1919-03-03");
 106     // ---------- */
 107     var navListItems = $('div.setup-panel div a'),
 108     allWells = $('.setup-content'),
 109     allNextBtn = $('.nextBtn'),
 110     allPrevBtn = $('.prevBtn');
 111
 112     allWells.hide();
 113
 114     navListItems.click(function (e) {
 115         e.preventDefault();
 116         var $target = $($(this).attr('href')),
 117         $item = $(this);
 118
 119         if (!$item.hasClass('disabled')) {
 120             navListItems.removeClass('btn-primary').addClass('btn-default');
 121             $item.addClass('btn-primary');
 122             allWells.hide();
 123             $target.show();
 124             $target.find('input:eq(0)').focus();
 125         }
 126     });
 127
 128     allPrevBtn.click(function () {
 129         var curStep = $(this).closest(".setup-content"),
 130         curStepBtn = curStep.attr("id"),
 131         prevstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().prev().children("a");
 132         prevstepwiz.removeAttr('disabled').trigger('click');
 133     });
 134
 135     allNextBtn.click(function () {
 136         var profile = $("#profileFrame").contents();
 137
 138         /* // test data
 139         profile.find("input#street").val("123 Some St.");
 140         profile.find("input#city").val("Brandon");
 141         //--------------------- */
 142
 143         var curStep = $(this).closest(".setup-content"),
 144         curStepBtn = curStep.attr("id"),
 145         nextstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().next().children("a"),
 146         curInputs = curStep.find("input[type='text'],input[type='email'],select"),
 147         isValid = true;
 148
 149         $(".form-group").removeClass("has-error");
 150         for (var i = 0; i < curInputs.length; i++) {
 151             if (!curInputs[i].validity.valid) {
 152                 isValid = false;
 153                 $(curInputs[i]).closest(".form-group").addClass("has-error");
 154             }
 155         }
 156         if (isValid) {
 157             if (curStepBtn == 'step-1') { // leaving step 1 setup profile frame. Prob not nec but in case
 158                 profile.find('input#fname').val($("#fname").val());
 159                 profile.find('input#mname').val($("#mname").val());
 160                 profile.find('input#lname').val($("#lname").val());
 161                 profile.find('input#dob').val($("#dob").val());
 162                 profile.find('input#email').val($("#emailInput").val());
 163                 profile.find('input[name=allowPatientPortal]').val(['YES']);
 164                 // need these for validation.
 165                 profile.find('select#providerid option:contains("Unassigned")').val('');
 166                 profile.find('select#providerid').attr('required', true);
 167                 profile.find('select#sex option:contains("Unassigned")').val('');
 168                 profile.find('select#sex').attr('required', true);
 169
 170                 var pid = profile.find('input#pid').val();
 171                 if (pid < 1) { // form pid set in promise
 172                     callServer('get_newpid', '', $("#dob").val(), $("#lname").val(), $("#fname").val()); // @TODO escape these
 173                 }
 174             }
 175             nextstepwiz.removeAttr('disabled').trigger('click');
 176         }
 177     });
 178
 179     $("#profileNext").click(function () {
 180         var profile = $("#profileFrame").contents();
 181         var curStep = $(this).closest(".setup-content"),
 182         curStepBtn = curStep.attr("id"),
 183         nextstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().next().children("a"),
 184         curInputs = $("#profileFrame").contents().find("input[type='text'],input[type='email'],select"),
 185         isValid = true;
 186         $(".form-group").removeClass("has-error");
 187         var flg = 0;
 188         for (var i = 0; i < curInputs.length; i++) {
 189             if (!curInputs[i].validity.valid) {
 190                 isValid = false;
 191                 if (!flg) {
 192                     curInputs[i].scrollIntoView();
 193                     curInputs[i].focus();
 194                     flg = 1;
 195                 }
 196                 $(curInputs[i]).closest(".form-group").addClass("has-error");
 197             }
 198         }
 199         if (isValid) {
 200             provider = profile.find('select#providerid').val();
 201             nextstepwiz.removeAttr('disabled').trigger('click');
 202         }
 203     });
 204
 205     $("#submitPatient").click(function () {
 206         var profile = $("#profileFrame").contents();
 207         var pid = profile.find('input#pid').val();
 208
 209         if (pid < 1) { // Just in case. Can never have too many pid checks!
 210             callServer('get_newpid', '');
 211         }
 212
 213         var isOk = checkRegistration(newPid);
 214         if (isOk) {
 215             // Use portals rest api. flag 1 is write to chart. flag 0 writes an audit record for review in dashboard.
 216             // rest update will determine if new or existing pid for save. In register step-1 we catch existing pid but,
 217             // we can still use update here if we want to allow changing passwords.
 218             //
 219             document.getElementById('profileFrame').contentWindow.page.updateModel(1);
 220             $("#insuranceForm").submit();
 221             //  cleanup is in callServer done promise. This starts end session.
 222         }
 223     });
 224
 225     $('div.setup-panel div a.btn-primary').trigger('click');
 226
 227     $('.datepicker').datetimepicker({
 228         <?php $datetimepicker_timepicker = false; ?>
 229         <?php $datetimepicker_showseconds = false; ?>
 230         <?php $datetimepicker_formatInput = false; ?>
 231         <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 232      });
 233
 234     $("#insuranceForm").submit(function (e) {
 235         e.preventDefault();
 236         var url = "account.php?action=new_insurance&pid=" + newPid;
 237         $.ajax({
 238             url: url,
 239             type: 'post',
 240             data: $("#insuranceForm").serialize(),
 241             success: function (serverResponse) {
 242                 doCredentials(newPid) // this is the end for session.
 243                 return false;
 244             }
 245         });
 246     });
 247
 248     $('#selLanguage').on('change', function () {
 249         callServer("set_lang", this.value);
 250     });
 251
 252     $(document.body).on('hidden.bs.modal', function () { //@TODO maybe make a promise for wiz exit
 253         callServer('cleanup');
 254     });
 255
 256     $('#inscompany').on('change', function () {
 257         if ($('#inscompany').val().toUpperCase() === 'SELF') {
 258             $("#insuranceForm input").removeAttr("required");
 259             let message = "<?php echo xls('You have chosen to be self insured or currently do not have insurance. Click next to continue registration.'); ?>";
 260             alert(message);
 261         }
 262     });
 263
 264 }); // ready end
 265
 266 function doCredentials(pid) {
 267     callServer('do_signup', pid);
 268 }
 269
 270 function checkRegistration(pid) {
 271     var profile = $("#profileFrame").contents();
 272     var curStep = $("#step-2"),
 273     curStepBtn = curStep.attr("id"),
 274     nextstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().next().children("a"),
 275     curInputs = $("#profileFrame").contents().find("input[type='text'],input[type='email'],select"),
 276     isValid = true;
 277     $(".form-group").removeClass("has-error");
 278     var flg = 0;
 279     for (var i = 0; i < curInputs.length; i++) {
 280         if (!curInputs[i].validity.valid) {
 281             isValid = false;
 282             if (!flg) {
 283                 curInputs[i].scrollIntoView();
 284                 curInputs[i].focus();
 285                 flg = 1;
 286             }
 287             $(curInputs[i]).closest(".form-group").addClass("has-error");
 288         }
 289     }
 290
 291     if (!isValid) {
 292         return false;
 293     }
 294
 295     return true;
 296 }
 297
 298 function callServer(action, value, value2, last, first) {
 299     var data = {
 300         'action' : action,
 301         'value' : value,
 302         'dob' : value2,
 303         'last' : last,
 304         'first' : first
 305     }
 306     if (action == 'do_signup') {
 307         data = {
 308             'action': action,
 309             'pid': value
 310         };
 311     }
 312     else if (action == 'notify_admin') {
 313         data = {
 314             'action': action,
 315             'pid': value,
 316             'provider': value2
 317         };
 318     }
 319     else if (action == 'cleanup') {
 320         data = {
 321             'action': action
 322         };
 323     }
 324     // The magic that is jquery ajax.
 325     $.ajax({
 326         type : 'GET',
 327         url : 'account.php',
 328         data : data
 329     }).done(function (rtn) {
 330         if (action == "cleanup") {
 331             window.location.href = "./../index.php" // Goto landing page.
 332         }
 333         else if (action == "set_lang") {
 334             window.location.href = window.location.href;
 335         }
 336         else if (action == "get_newpid") {
 337             if (parseInt(rtn) > 0) {
 338                 newPid = rtn;
 339                 $("#profileFrame").contents().find('input#pubpid').val(newPid);
 340                 $("#profileFrame").contents().find('input#pid').val(newPid);
 341             }
 342             else {
 343                 // After error alert app exit to landing page.
 344                 // Existing user error. Error message is translated in account.lib.php.
 345                 eModal.alert(rtn);
 346             }
 347         }
 348         else if (action == 'do_signup') {
 349             if (rtn == "") {
 350                 let message = "<?php echo xls('Unable to either create credentials or send email.'); ?>";
 351                 alert(message);
 352                 return false;
 353             }
 354             // For production. Here we're finished so do signup closing alert and then cleanup.
 355             callServer('notify_admin', newPid, provider); // pnote notify to selected provider
 356             // alert below for ease of testing.
 357             //alert(rtn); // sync alert.. rtn holds username and password for testing.
 358
 359             let message = "<?php echo xls("Your new credentials have been sent. Check your email inbox and also possibly your spam folder. Once you log into your patient portal feel free to make an appointment or send us a secure message. We look forward to seeing you soon."); ?>"
 360             eModal.alert(message); // This is an async call. The modal close event exits us to portal landing page after cleanup.
 361         }
 362     }).fail(function (err) {
 363         let message = "<?php echo xls('Something went wrong.') ?>";
 364         alert(message);
 365     });
 366 }
 367 </script>
 368 </head>
 369 <body class="skin-blue">
 370     <div class="container">
 371         <div class="stepwiz col-md-offset-3">
 372             <div class="stepwiz-row setup-panel">
 373                 <div class="stepwiz-step">
 374                     <a href="#step-1" type="button" class="btn btn-primary btn-circle">1</a>
 375                     <p><?php echo xlt('Get Started') ?></p>
 376                 </div>
 377                 <div class="stepwiz-step">
 378                     <a href="#step-2" type="button" class="btn btn-default btn-circle" disabled="disabled">2</a>
 379                     <p><?php echo xlt('Profile') ?></p>
 380                 </div>
 381                 <div class="stepwiz-step">
 382                     <a href="#step-3" type="button" class="btn btn-default btn-circle" disabled="disabled">3</a>
 383                     <p><?php echo xlt('Insurance') ?></p>
 384                 </div>
 385                 <div class="stepwiz-step">
 386                     <a href="#step-4" type="button" class="btn btn-default btn-circle" disabled="disabled"><?php echo xlt('Done') ?></a>
 387                     <p><?php echo xlt('Register') ?></p>
 388                 </div>
 389             </div>
 390         </div>
 391 <!-- // Start Forms // -->
 392         <form class="form-inline" id="startForm" role="form" action="" method="post" onsubmit="">
 393             <div class="row setup-content" id="step-1">
 394                 <div class="col-xs-7 col-md-offset-3 text-center">
 395                     <fieldset>
 396                         <legend class='bg-primary'><?php echo xlt('Contact') ?></legend>
 397                         <div class="well">
 398                         <?php if ($GLOBALS['language_menu_login']) { ?>
 399                         <?php if (count($result3) != 1) { ?>
 400                         <div class="form-group row">
 401                             <label for="selLanguage"><?php echo xlt('Language'); ?></label>
 402                             <select class="form-control" id="selLanguage" name="languageChoice">
 403                             <?php
 404                                 echo "<option selected='selected' value='" . htmlspecialchars($defaultLangID, ENT_QUOTES) . "'>" .
 405                                      htmlspecialchars(xl('Default') . " - " . xl($defaultLangName), ENT_NOQUOTES) . "</option>\n";
 406                             foreach ($result3 as $iter) {
 407                                 if ($GLOBALS['language_menu_showall']) {
 408                                     if (! $GLOBALS['allow_debug_language'] && $iter['lang_description'] == 'dummy') {
 409                                         continue; // skip the dummy language
 410                                     }
 411                                     echo "<option value='" . htmlspecialchars($iter['lang_id'], ENT_QUOTES) . "'>" .
 412                                          htmlspecialchars($iter['trans_lang_description'], ENT_NOQUOTES) . "</option>\n";
 413                                 } else {
 414                                     if (in_array($iter['lang_description'], $GLOBALS['language_menu_show'])) {
 415                                         if (! $GLOBALS['allow_debug_language'] && $iter['lang_description'] == 'dummy') {
 416                                             continue; // skip the dummy language
 417                                         }
 418                                         echo "<option value='" . htmlspecialchars($iter['lang_id'], ENT_QUOTES) . "'>" .
 419                                              htmlspecialchars($iter['trans_lang_description'], ENT_NOQUOTES) . "</option>\n";
 420                                     }
 421                                 }
 422                             }
 423                             ?>
 424                           </select>
 425                         </div>
 426                         <?php } } ?>
 427                         <div class="row">
 428                                 <div class="col-sm-12">
 429                                     <div class="form-group inline">
 430                                         <label class="control-label" for="fname"><?php echo xlt('First')?></label>
 431                                         <div class="controls inline-inputs">
 432                                             <input type="text" class="form-control" id="fname" required placeholder="<?php echo xla('First Name'); ?>">
 433                                         </div>
 434                                     </div>
 435                                     <div class="form-group inline">
 436                                         <label class="control-label" for="mname"><?php echo xlt('Middle')?></label>
 437                                         <div class="controls inline-inputs">
 438                                             <input type="text" class="form-control" id="mname" placeholder="<?php echo xla('Full or Initial'); ?>">
 439                                         </div>
 440                                     </div>
 441                                     <div class="form-group inline">
 442                                         <label class="control-label" for="lname"><?php echo xlt('Last Name')?></label>
 443                                         <div class="controls inline-inputs">
 444                                             <input type="text" class="form-control" id="lname" required placeholder="<?php echo xla('Enter Last'); ?>">
 445                                         </div>
 446                                     </div>
 447                                 </div>
 448                             </div>
 449                             <div class="form-group inline">
 450                                 <label class="control-label" for="dob"><?php echo xlt('Birth Date')?></label>
 451                                 <div class="controls inline-inputs">
 452                                     <div class="input-group">
 453                                         <input id="dob" type="text" required class="form-control datepicker" placeholder="<?php echo xla('YYYY-MM-DD'); ?>" />
 454                                     </div>
 455                                 </div>
 456                             </div>
 457                             <div class="row">
 458                                 <div class="col-sm-12 form-group">
 459                                     <label class="control-label" for="email"><?php echo xlt('Enter E-Mail Address')?></label>
 460                                     <div class="controls inline-inputs">
 461                                         <input id="emailInput" type="email" class="form-control" style="width: 100%" required
 462                                             placeholder="<?php echo xla('Enter email address to receive registration.'); ?>" maxlength="100">
 463                                     </div>
 464                                 </div>
 465                             </div>
 466                         </div>
 467                         <button class="btn btn-primary nextBtn btn-sm pull-right" type="button"><?php echo xlt('Next') ?></button>
 468                     </fieldset>
 469                 </div>
 470             </div>
 471         </form>
 472 <!-- Profile Form -->
 473         <form class="form-inline" id="profileForm" role="form" action="account.php" method="post">
 474             <div class="row setup-content" id="step-2" style="display: none">
 475                 <div class="col-md-9 col-md-offset-2 text-center">
 476                     <fieldset>
 477                         <legend class='bg-primary'><?php echo xlt('Profile') ?></legend>
 478                         <div class="well">
 479                             <div class="embed-responsive embed-responsive-16by9">
 480                                 <iframe class="embed-responsive-item" src="../patient/patientdata?pid=0&register=true" id="profileFrame" name="demo"></iframe>
 481                             </div>
 482                         </div>
 483                         <button class="btn btn-primary prevBtn btn-sm pull-left" type="button"><?php echo xlt('Previous') ?></button>
 484                         <button class="btn btn-primary btn-sm pull-right" type="button" id="profileNext"><?php echo xlt('Next') ?></button>
 485                     </fieldset>
 486                 </div>
 487             </div>
 488         </form>
 489 <!-- Insurance Form -->
 490         <form class="form-inline" id="insuranceForm" role="form" action="" method="post">
 491             <div class="row setup-content" id="step-3" style="display: none">
 492                 <div class="col-xs-6 col-md-offset-3 text-center">
 493                     <fieldset>
 494                         <legend class='bg-primary'><?php echo xlt('Insurance') ?></legend>
 495                         <div class="well">
 496                             <div class="form-group inline">
 497                                 <label class="control-label" for="provider"><?php echo xlt('Insurance Company')?></label>
 498                                 <div class="controls inline-inputs">
 499                                     <input type="text" class="form-control" name="provider" id="inscompany" required placeholder="<?php echo xla('Enter Self if None'); ?>">
 500                                 </div>
 501                             </div>
 502                             <div class="form-group inline">
 503                                 <label class="control-label" for=""><?php echo xlt('Plan Name')?></label>
 504                                 <div class="controls inline-inputs">
 505                                     <input type="text" class="form-control" name="plan_name" required placeholder="<?php echo xla('Required'); ?>">
 506                                 </div>
 507                             </div>
 508                             <div class="form-group inline">
 509                                 <label class="control-label" for=""><?php echo xlt('Policy Number')?></label>
 510                                 <div class="controls inline-inputs">
 511                                     <input type="text" class="form-control" name="policy_number" required placeholder="<?php echo xla('Required'); ?>">
 512                                 </div>
 513                             </div>
 514                             <div class="form-group inline">
 515                                 <label class="control-label" for=""><?php echo xlt('Group Number')?></label>
 516                                 <div class="controls inline-inputs">
 517                                     <input type="text" class="form-control" name="group_number" required placeholder="<?php echo xla('Required'); ?>">
 518                                 </div>
 519                             </div>
 520                             <div class="form-group inline">
 521                                 <label class="control-label" for=""><?php echo xlt('Policy Begin Date')?></label>
 522                                 <div class="controls inline-inputs">
 523                                     <input type="text" class="form-control datepicker" name="date" placeholder="<?php echo xla('Policy effective date'); ?>">
 524                                 </div>
 525                             </div>
 526                             <div class="form-group inline">
 527                                 <label class="control-label" for=""><?php echo xlt('Co-Payment')?></label>
 528                                 <div class="controls inline-inputs">
 529                                     <input type="number" class="form-control" name="copay" placeholder="<?php echo xla('Plan copay if known'); ?>">
 530                                 </div>
 531                             </div>
 532                         </div>
 533                         <button class="btn btn-primary prevBtn btn-sm pull-left" type="button"><?php echo xlt('Previous') ?></button>
 534                         <button class="btn btn-primary nextBtn btn-sm pull-right" type="button"><?php echo xlt('Next') ?></button>
 535                     </fieldset>
 536                 </div>
 537             </div>
 538         </form>
 539         <!-- End Insurance. Next what we've been striving towards..the end-->
 540         <div class="row setup-content" id="step-4" style="display: none">
 541             <div class="col-xs-6 col-md-offset-3 text-center">
 542                 <div class="col-md-12">
 543                     <fieldset>
 544                         <legend class='bg-success'><?php echo xlt('Register') ?></legend>
 545                         <div class="well" style="text-align: center">
 546                             <h4 class='bg-success'><?php echo xlt("All set. Click Send Request below to finish registration") ?></h4>
 547                             <hr>
 548                             <p>
 549                             <?php echo xlt("An e-mail with your new account credentials will be sent to the e-mail address supplied earlier. You may still review or edit any part of your information by using the top step buttons to go to the appropriate panels. Note to be sure you have given your correct e-mail address. If after receiving credentials and you have trouble with access to the portal, please contact administration.") ?>
 550                             </p>
 551                         </div>
 552                         <button class="btn btn-primary prevBtn btn-sm pull-left" type="button"><?php echo xlt('Previous') ?></button>
 553                         <hr>
 554                         <button class="btn btn-success btn-sm pull-right" type="button" id="submitPatient"><?php echo xlt('Send Request') ?></button>
 555                     </fieldset>
 556                 </div>
 557             </div>
 558         </div>
 559     </div>
 560 </body>
 561 </html>