portal/account/register.php

   1 <?php
   2
   3 /**
   4  * Portal Registration Wizard
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    Jerry Padgett <sjpadgett@gmail.com>
   9  * @author    Brady Miller <brady.g.miller@gmail.com>
  10  * @copyright Copyright (c) 2017-2019 Jerry Padgett <sjpadgett@gmail.com>
  11  * @copyright Copyright (c) 2019 Brady Miller <brady.g.miller@gmail.com>
  12  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  13  */
  14
  15 use OpenEMR\Core\Header;
  16
  17 // Will start the (patient) portal OpenEMR session/cookie.
  18 require_once(dirname(__FILE__) . "/../../src/Common/Session/SessionUtil.php");
  19 OpenEMR\Common\Session\SessionUtil::portalSessionStart();
  20 session_regenerate_id(true);
  21
  22 unset($_SESSION['itsme']);
  23 $_SESSION['authUser'] = 'portal-user';
  24 $_SESSION['pid'] = true;
  25 $_SESSION['register'] = true;
  26
  27 $_SESSION['site_id'] = isset($_SESSION['site_id']) ? $_SESSION['site_id'] : 'default';
  28 $landingpage = "index.php?site=" . urlencode($_SESSION['site_id']);
  29
  30 $ignoreAuth_onsite_portal = true;
  31
  32 require_once("../../interface/globals.php");
  33 if (!$GLOBALS['portal_onsite_two_register']) {
  34     OpenEMR\Common\Session\SessionUtil::portalSessionCookieDestroy();
  35     echo xlt("Not Authorized");
  36     @header('HTTP/1.1 401 Unauthorized');
  37     die();
  38 }
  39
  40 $res2 = sqlStatement("select * from lang_languages where lang_description = ?", array(
  41     $GLOBALS['language_default']
  42 ));
  43 for ($iter = 0; $row = sqlFetchArray($res2); $iter++) {
  44     $result2[$iter] = $row;
  45 }
  46 if (count($result2) == 1) {
  47     $defaultLangID = $result2[0]["lang_id"];
  48     $defaultLangName = $result2[0]["lang_description"];
  49 } else {
  50     // default to english if any problems
  51     $defaultLangID = 1;
  52     $defaultLangName = "English";
  53 }
  54
  55 if (!isset($_SESSION['language_choice'])) {
  56     $_SESSION['language_choice'] = $defaultLangID;
  57 }
  58 // collect languages if showing language menu
  59 if ($GLOBALS['language_menu_login']) {
  60     // sorting order of language titles depends on language translation options.
  61     $mainLangID = empty($_SESSION['language_choice']) ? '1' : $_SESSION['language_choice'];
  62     // Use and sort by the translated language name.
  63     $sql = "SELECT ll.lang_id, " . "IF(LENGTH(ld.definition),ld.definition,ll.lang_description) AS trans_lang_description, " . "ll.lang_description " .
  64         "FROM lang_languages AS ll " . "LEFT JOIN lang_constants AS lc ON lc.constant_name = ll.lang_description " .
  65         "LEFT JOIN lang_definitions AS ld ON ld.cons_id = lc.cons_id AND " . "ld.lang_id = ? " .
  66         "ORDER BY IF(LENGTH(ld.definition),ld.definition,ll.lang_description), ll.lang_id";
  67     $res3 = SqlStatement($sql, array(
  68         $mainLangID
  69     ));
  70
  71     for ($iter = 0; $row = sqlFetchArray($res3); $iter++) {
  72         $result3[$iter] = $row;
  73     }
  74
  75     if (count($result3) == 1) {
  76         // default to english if only return one language
  77         $hiddenLanguageField = "<input type='hidden' name='languageChoice' value='1' />\n";
  78     }
  79 } else {
  80     $hiddenLanguageField = "<input type='hidden' name='languageChoice' value='" . attr($defaultLangID) . "' />\n";
  81 }
  82
  83 ?>
  84 <!DOCTYPE html>
  85 <html>
  86 <head>
  87     <title><?php echo xlt('New Patient'); ?> | <?php echo xlt('Register'); ?></title>
  88     <meta name="description" content="Developed By sjpadgett@gmail.com" />
  89
  90     <?php Header::setupHeader(['no_main-theme', 'datetime-picker', 'patientportal-style', 'patientportal-register']); ?>
  91
  92     <script>
  93         var webRoot = <?php echo js_escape($GLOBALS['web_root']); ?>;
  94         top.webroot_url = webRoot;
  95         var newPid = 0;
  96         var curPid = 0;
  97         var provider = 0;
  98
  99         function restoreSession() {
 100             //dummy functions so the dlgopen function will work in the patient portal
 101             return true;
 102         }
 103         $(function () {
 104             var navListItems = $('div.setup-panel div a'),
 105                 allWells = $('.setup-content'),
 106                 allNextBtn = $('.nextBtn'),
 107                 allPrevBtn = $('.prevBtn');
 108
 109             allWells.hide();
 110
 111             navListItems.click(function (e) {
 112                 e.preventDefault();
 113                 if (!$(this).hasClass('disabled')) {
 114                     navListItems.removeClass('btn-primary').addClass('btn-light');
 115                     $(this).addClass('btn-primary').removeClass('btn-light');
 116                     allWells.hide();
 117                     $($(this).attr('href')).show();
 118                     $($(this).attr('href')).find('input:eq(0)').focus();
 119                 }
 120             });
 121
 122             allPrevBtn.click(function () {
 123                 var curStep = $(this).closest(".setup-content"),
 124                     curStepBtn = curStep.attr("id"),
 125                     prevstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().prev().children("a");
 126                 prevstepwiz.removeClass('disabled').trigger('click');
 127             });
 128
 129             allNextBtn.click(function () {
 130                 var profile = $("#profileFrame").contents();
 131
 132                 // Fix for iFrame height
 133                 window.addEventListener('message', function(e) {
 134                     var scroll_height = e.data;
 135                     document.getElementById('profileFrame').style.height = scroll_height + 'px';
 136                 }, false);
 137
 138                 var curStep = $(this).closest(".setup-content"),
 139                     curStepBtn = curStep.attr("id"),
 140                     nextstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().next().children("a"),
 141                     curInputs = curStep.find("input[type='text'],input[type='email'],select"),
 142                     isValid = true;
 143
 144                 $(".form-group").removeClass("has-error");
 145                 for (var i = 0; i < curInputs.length; i++) {
 146                     if (!curInputs[i].validity.valid) {
 147                         isValid = false;
 148                         $(curInputs[i]).closest(".form-group").addClass("has-error");
 149                     }
 150                 }
 151                 if (isValid) {
 152                     if (curStepBtn == 'step-1') { // leaving step 1 setup profile frame. Prob not nec but in case
 153                     let fn = $("#fname").val().replace(/^./, $("#fname").val()[0].toUpperCase());
 154                     let ln = $("#lname").val().replace(/^./, $("#lname").val()[0].toUpperCase());
 155                     profile.find('input#fname').val(fn);
 156                         profile.find('input#mname').val($("#mname").val());
 157                     profile.find('input#lname').val(ln);
 158                         profile.find('input#dob').val($("#dob").val());
 159                         profile.find('input#email').val($("#emailInput").val());
 160                     profile.find('input#emailDirect').val($("#emailInput").val());
 161                     // disable to prevent already validated field changes.
 162                     profile.find('input#fname').prop("disabled", true);
 163                     profile.find('input#mname').prop("disabled", true);
 164                     profile.find('input#lname').prop("disabled", true);
 165                     profile.find('input#dob').prop("disabled", true);
 166                     profile.find('input#email').prop("disabled", true);
 167                     profile.find('input#emailDirect').prop("disabled", true);
 168
 169                         profile.find('input[name=allowPatientPortal]').val(['YES']);
 170                     profile.find('input[name=hipaaAllowemail]').val(['YES']);
 171                         // need these for validation.
 172                         profile.find('select#providerid option:contains("Unassigned")').val('');
 173                     // must have a provider for many reasons. w/o save won't work.
 174                         //profile.find('select#providerid').attr('required', true);
 175                         profile.find('select#sex option:contains("Unassigned")').val('');
 176                         profile.find('select#sex').attr('required', true);
 177
 178                         var pid = profile.find('input#pid').val();
 179                         if (pid < 1) { // form pid set in promise
 180                         callServer('get_newpid', '',
 181                             encodeURIComponent($("#dob").val()),
 182                             encodeURIComponent($("#lname").val()),
 183                             encodeURIComponent($("#fname").val()),
 184                             encodeURIComponent($("#emailInput").val()));
 185                         }
 186                     }
 187                     nextstepwiz.removeClass('disabled').trigger('click');
 188                 }
 189             });
 190
 191             $("#profileNext").click(function () {
 192                 var profile = $("#profileFrame").contents();
 193                 var curStep = $(this).closest(".setup-content"),
 194                     curStepBtn = curStep.attr("id"),
 195                     nextstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().next().children("a"),
 196                     curInputs = $("#profileFrame").contents().find("input[type='text'],input[type='email'],select"),
 197                     isValid = true;
 198                 $(".form-group").removeClass("has-error");
 199                 var flg = 0;
 200                 for (var i = 0; i < curInputs.length; i++) {
 201                     if (!curInputs[i].validity.valid) {
 202                         isValid = false;
 203                         if (!flg) {
 204                             curInputs[i].scrollIntoView();
 205                             curInputs[i].focus();
 206                             flg = 1;
 207                         }
 208                         $(curInputs[i]).closest(".form-group").addClass("has-error");
 209                     }
 210                 }
 211             // test for new once again
 212             // this time using the profile data that will be saved as new patient.
 213             // callserver will intercept on fail or silence to continue.
 214             let stillNew = callServer('get_newpid', '',
 215                 encodeURIComponent(profile.find('input#dob').val()),
 216                 encodeURIComponent(profile.find('input#lname').val()),
 217                 encodeURIComponent(profile.find('input#fname').val()),
 218                 encodeURIComponent(profile.find('input#email').val()));
 219                 if (isValid) {
 220                     provider = profile.find('select#providerid').val();
 221                     nextstepwiz.removeClass('disabled').trigger('click');
 222                 }
 223             });
 224
 225             $("#submitPatient").click(function () {
 226                 var profile = $("#profileFrame").contents();
 227                 var pid = profile.find('input#pid').val();
 228
 229                 if (pid < 1) {
 230                     callServer('get_newpid', '');
 231                 }
 232
 233                 var isOk = checkRegistration(newPid);
 234                 if (isOk) {
 235                     // Use portals rest api. flag 1 is write to chart. flag 0 writes an audit record for review in dashboard.
 236                     // rest update will determine if new or existing pid for save. In register step-1 we catch existing pid but,
 237                     // we can still use update here if we want to allow changing passwords.
 238
 239                     // save the new patient.
 240                     document.getElementById('profileFrame').contentWindow.postMessage({submitForm: true}, window.location.origin);
 241                     $("#insuranceForm").submit();
 242                     //  cleanup is in callServer done promise. This starts end session.
 243                 }
 244             });
 245
 246             $('div.setup-panel div a.btn-primary').trigger('click');
 247
 248             $('.datepicker').datetimepicker({
 249                 <?php $datetimepicker_timepicker = false; ?>
 250                 <?php $datetimepicker_showseconds = false; ?>
 251                 <?php $datetimepicker_formatInput = false; ?>
 252                 <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
 253             });
 254
 255             $("#insuranceForm").submit(function (e) {
 256                 e.preventDefault();
 257                 var url = "account.php?action=new_insurance&pid=" + encodeURIComponent(newPid);
 258                 $.ajax({
 259                     url: url,
 260                     type: 'post',
 261                     data: $("#insuranceForm").serialize(),
 262                     success: function (serverResponse) {
 263                         doCredentials(newPid) // this is the end for session.
 264                         return false;
 265                     }
 266                 });
 267             });
 268
 269             $('#selLanguage').on('change', function () {
 270                 callServer("set_lang", this.value);
 271             });
 272
 273             $(document.body).on('hidden.bs.modal', function () { //@TODO maybe make a promise for wiz exit
 274                 callServer('cleanup');
 275             });
 276
 277             $('#inscompany').on('change', function () {
 278                 if ($('#inscompany').val().toUpperCase() === 'SELF') {
 279                     $("#insuranceForm input").removeAttr("required");
 280                     let message = <?php echo xlj('You have chosen to be self insured or currently do not have insurance. Click next to continue registration.'); ?>;
 281                     alert(message);
 282                 }
 283             });
 284
 285         $("#dob").on('blur', function () {
 286             let bday = $(this).val() ?? '';
 287             let age = Math.round(Math.abs((new Date().getTime() - new Date(bday).getTime())));
 288             age = Math.round(age / 1000 / 60 / 60 / 24);
 289             // need to be at least 30 days old otherwise likely an error.
 290             if (age < 30) {
 291                 let msg = <?php echo (xlj("Invalid Date format or value! Type date as YYYY-MM-DD or use the calendar.") ); ?> ;
 292                 $(this).val('');
 293                 $(this).prop('placeholder', 'Invalid Date');
 294                 alert(msg);
 295                 return false;
 296             }
 297         });
 298
 299         }); // ready end
 300
 301         function doCredentials(pid) {
 302             callServer('do_signup', pid);
 303         }
 304
 305         function checkRegistration(pid) {
 306             var profile = $("#profileFrame").contents();
 307             var curStep = $("#step-2"),
 308                 curStepBtn = curStep.attr("id"),
 309                 nextstepwiz = $('div.setup-panel div a[href="#' + curStepBtn + '"]').parent().next().children("a"),
 310                 curInputs = $("#profileFrame").contents().find("input[type='text'],input[type='email'],select"),
 311                 isValid = true;
 312             $(".form-group").removeClass("has-error");
 313             var flg = 0;
 314             for (var i = 0; i < curInputs.length; i++) {
 315                 if (!curInputs[i].validity.valid) {
 316                     isValid = false;
 317                     if (!flg) {
 318                         curInputs[i].scrollIntoView();
 319                         curInputs[i].focus();
 320                         flg = 1;
 321                     }
 322                     $(curInputs[i]).closest(".form-group").addClass("has-error");
 323                 }
 324             }
 325
 326             if (!isValid) {
 327                 return false;
 328             }
 329
 330             return true;
 331         }
 332
 333     function callServer(action, value, value2, last, first, email = null) {
 334             let message = '';
 335             let data = {
 336                 'action': action,
 337                 'value': value,
 338                 'dob': value2,
 339                 'last': last,
 340                 'first': first,
 341                 'email': email
 342             }
 343             if (action == 'do_signup') {
 344                 data = {
 345                     'action': action,
 346                     'pid': value
 347                 };
 348             } else if (action == 'notify_admin') {
 349                 data = {
 350                     'action': action,
 351                     'pid': value,
 352                     'provider': value2
 353                 };
 354             } else if (action == 'cleanup') {
 355                 data = {
 356                     'action': action
 357                 };
 358             }
 359             // The magic that is jquery ajax.
 360             $.ajax({
 361                 type: 'GET',
 362                 url: 'account.php',
 363                 data: data
 364             }).done(function (rtn) {
 365                 if (action == "cleanup") {
 366                 window.location.href = "./../index.php" // Goto landing page.
 367                 } else if (action == "set_lang") {
 368                     window.location.href = window.location.href;
 369                 } else if (action == "get_newpid") {
 370                     if (parseInt(rtn) > 0) {
 371                         newPid = rtn;
 372                         $("#profileFrame").contents().find('input#pubpid').val(newPid);
 373                         $("#profileFrame").contents().find('input#pid').val(newPid);
 374                     } else {
 375                         // After error alert app exit to landing page.
 376                         // Existing user error. Error message is translated in account.lib.php.
 377                         dialog.alert(rtn);
 378                     }
 379                 } else if (action == 'do_signup') {
 380                     if (rtn.indexOf('ERROR') !== -1) {
 381                         message = <?php echo xlj('Unable to either create credentials or send email.'); ?>;
 382                         message += "<br /><br />" + <?php echo xlj('Here is what we do know.'); ?> +": " + rtn + "<br />";
 383                         dialog.alert(message);
 384                         return false;
 385                     }
 386                     // For production. Here we're finished so do signup closing alert and then cleanup.
 387                     callServer('notify_admin', newPid, provider); // pnote notify to selected provider
 388                     // alert below for ease of testing.
 389                     //alert(rtn); // sync alert.. rtn holds username and password for testing.
 390
 391                     message = <?php echo xlj("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."); ?>;
 392                     dialog.alert(message); // This is an async call. The modal close event exits us to portal landing page after cleanup.
 393                     return false;
 394                 }
 395             }).fail(function (err) {
 396                 message = <?php echo xlj('Something went wrong.') ?>;
 397                 alert(message);
 398             });
 399         }
 400     </script>
 401 </head>
 402 <body class="mt-4 skin-blue">
 403     <div class="container">
 404         <h1 class="text-center"><?php echo xlt('Account Registration'); ?></h1>
 405         <div class="stepwiz">
 406             <div class="stepwiz-row setup-panel">
 407                 <div class="stepwiz-step">
 408                     <a href="#step-1" type="button" class="btn btn-primary btn-circle">1</a>
 409                     <p><?php echo xlt('Get Started') ?></p>
 410                 </div>
 411                 <div class="stepwiz-step">
 412                     <a href="#step-2" type="button" class="btn btn-light btn-circle disabled">2</a>
 413                     <p><?php echo xlt('Profile') ?></p>
 414                 </div>
 415                 <div class="stepwiz-step">
 416                     <a href="#step-3" type="button" class="btn btn-light btn-circle disabled">3</a>
 417                     <p><?php echo xlt('Insurance') ?></p>
 418                 </div>
 419                 <div class="stepwiz-step">
 420                     <a href="#step-4" type="button" class="btn btn-light btn-circle disabled">4</a>
 421                     <p><?php echo xlt('Register') ?></p>
 422                 </div>
 423             </div>
 424         </div>
 425         <!-- // Start Forms // -->
 426         <form id="startForm" role="form" action="" method="post" onsubmit="">
 427             <div class="text-center setup-content" id="step-1">
 428                 <legend class="bg-primary text-white"><?php echo xlt('Contact Information') ?></legend>
 429                 <div class="jumbotron">
 430                     <?php if ($GLOBALS['language_menu_login']) { ?>
 431                         <?php if (count($result3) != 1) { ?>
 432                             <div class="form-group">
 433                                 <label class="col-form-label" for="selLanguage"><?php echo xlt('Language'); ?></label>
 434                                 <select class="form-control" id="selLanguage" name="languageChoice">
 435                                     <?php
 436                                     echo "<option selected='selected' value='" . attr($defaultLangID) . "'>" .
 437                                         text(xl('Default') . " - " . xl($defaultLangName)) . "</option>\n";
 438                                     foreach ($result3 as $iter) {
 439                                         if ($GLOBALS['language_menu_showall']) {
 440                                             if (!$GLOBALS['allow_debug_language'] && $iter['lang_description'] == 'dummy') {
 441                                                 continue; // skip the dummy language
 442                                             }
 443                                             echo "<option value='" . attr($iter['lang_id']) . "'>" .
 444                                                 text($iter['trans_lang_description']) . "</option>\n";
 445                                         } else {
 446                                             if (in_array($iter['lang_description'], $GLOBALS['language_menu_show'])) {
 447                                                 if (!$GLOBALS['allow_debug_language'] && $iter['lang_description'] == 'dummy') {
 448                                                     continue; // skip the dummy language
 449                                                 }
 450                                                 echo "<option value='" . attr($iter['lang_id']) . "'>" .
 451                                                     text($iter['trans_lang_description']) . "</option>\n";
 452                                             }
 453                                         }
 454                                     }
 455                                     ?>
 456                                 </select>
 457                             </div>
 458                         <?php }
 459                     } ?>
 460                     <div class="form-row">
 461                         <div class="col form-group">
 462                           <label for="fname"><?php echo xlt('First Name') ?></label>
 463                           <input type="text" class="form-control" id="fname" required placeholder="<?php echo xla('First Name'); ?>" />
 464                         </div>
 465                         <div class="col form-group">
 466                           <label for="mname"><?php echo xlt('Middle Name') ?></label>
 467                           <input type="text" class="form-control" id="mname" placeholder="<?php echo xla('Full or Initial'); ?>" />
 468                         </div>
 469                         <div class="col form-group">
 470                           <label for="lname"><?php echo xlt('Last Name') ?></label>
 471                           <input type="text" class="form-control" id="lname" required placeholder="<?php echo xla('Enter Last'); ?>" />
 472                         </div>
 473                         <div class="col form-group">
 474                           <label for="dob"><?php echo xlt('Birth Date') ?></label>
 475                           <input id="dob" type="text" required class="form-control datepicker" placeholder="<?php echo xla('YYYY-MM-DD'); ?>" />
 476                         </div>
 477                     </div>
 478                     <div class="form-group">
 479                         <label class="col-form-label" for="emailInput"><?php echo xlt('Enter E-Mail Address') ?></label>
 480                         <input id="emailInput" type="email" class="reg-email form-control" required placeholder="<?php echo xla('Enter email address to receive registration.'); ?>" maxlength="100" />
 481                     </div>
 482                 </div>
 483
 484                 <button class="btn btn-primary nextBtn pull-right" type="button"><?php echo xlt('Next') ?></button>
 485             </div>
 486         </form>
 487         <!-- Profile Form -->
 488         <form id="profileForm" role="form" action="account.php" method="post">
 489             <div class="text-center setup-content" id="step-2" style="display: none">
 490                 <legend class="bg-primary text-white"><?php echo xlt('Profile') ?></legend>
 491                 <div class="jumbotron">
 492                     <iframe class="embedded-content" src="../patient/patientdata?pid=0&register=true" id="profileFrame" name="Profile Info"></iframe>
 493                 </div>
 494                 <button class="btn btn-primary prevBtn pull-left" type="button"><?php echo xlt('Previous') ?></button>
 495                 <button class="btn btn-primary pull-right" type="button" id="profileNext"><?php echo xlt('Next') ?></button>
 496             </div>
 497         </form>
 498         <!-- Insurance Form -->
 499         <form id="insuranceForm" role="form" action="" method="post">
 500             <div class="text-center setup-content" id="step-3" style="display: none">
 501                 <legend class='bg-primary text-white'><?php echo xlt('Insurance') ?></legend>
 502                 <div class="jumbotron">
 503                     <div class="form-row">
 504                         <div class="col form-group">
 505                             <label for="provider"><?php echo xlt('Insurance Company') ?></label>
 506                             <div class="controls inline-inputs">
 507                                 <input type="text" class="form-control" name="provider" id="inscompany" required placeholder="<?php echo xla('Enter Self if None'); ?>">
 508                             </div>
 509                         </div>
 510                         <div class="col form-group">
 511                             <label for="plan_name"><?php echo xlt('Plan Name') ?></label>
 512                             <div class="controls inline-inputs">
 513                                 <input type="text" class="form-control" name="plan_name" required placeholder="<?php echo xla('required'); ?>">
 514                             </div>
 515                         </div>
 516                         <div class="col form-group">
 517                             <label for="policy_number"><?php echo xlt('Policy Number') ?></label>
 518                             <div class="controls inline-inputs">
 519                                 <input type="text" class="form-control" name="policy_number" required placeholder="<?php echo xla('required'); ?>">
 520                             </div>
 521                         </div>
 522                       </div>
 523                       <div class="form-row">
 524                         <div class="col form-group">
 525                             <label for="group_number"><?php echo xlt('Group Number') ?></label>
 526                             <div class="controls inline-inputs">
 527                                 <input type="text" class="form-control" name="group_number" required placeholder="<?php echo xla('required'); ?>">
 528                             </div>
 529                         </div>
 530                         <div class="col form-group">
 531                             <label for="date"><?php echo xlt('Policy Begin Date') ?></label>
 532                             <div class="controls inline-inputs">
 533                                 <input type="text" class="form-control datepicker" name="date" placeholder="<?php echo xla('Policy effective date'); ?>">
 534                             </div>
 535                         </div>
 536                         <div class="col form-group">
 537                             <label for="copay"><?php echo xlt('Co-Payment') ?></label>
 538                             <div class="controls inline-inputs">
 539                                 <input type="number" class="form-control" name="copay" placeholder="<?php echo xla('Plan copay if known'); ?>">
 540                             </div>
 541                         </div>
 542                     </div>
 543                 </div>
 544                 <button class="btn btn-primary prevBtn btn-sm pull-left" type="button"><?php echo xlt('Previous') ?></button>
 545                 <button class="btn btn-primary nextBtn btn-sm pull-right" type="button"><?php echo xlt('Next') ?></button>
 546             </div>
 547         </form>
 548         <!-- End Insurance. Next what we've been striving towards..the end-->
 549         <div class="text-center setup-content" id="step-4" style="display: none">
 550             <legend class='bg-success text-white'><?php echo xlt('Register') ?></legend>
 551             <div class="jumbotron">
 552                 <h4 class='bg-success'><?php echo xlt("All set. Click Send Request below to finish registration.") ?></h4>
 553                 <hr />
 554                 <p>
 555                     <?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.") ?>
 556                 </p>
 557             </div>
 558             <hr />
 559             <button class="btn btn-primary prevBtn float-left" type="button"><?php echo xlt('Previous') ?></button>
 560             <button class="btn btn-success float-right" type="button" id="submitPatient"><?php echo xlt('Send Request') ?></button>
 561         </div>
 562     </div>
 563 </body>
 564 </html>