{"id":4907,"date":"2023-06-15T07:38:47","date_gmt":"2023-06-15T07:38:47","guid":{"rendered":"https:\/\/ems.hayeshandpiece.com.au\/?page_id=4907"},"modified":"2024-03-02T14:34:43","modified_gmt":"2024-03-02T03:34:43","slug":"ems-airflow-request","status":"publish","type":"page","link":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/ems-airflow-request\/","title":{"rendered":"New EMS Airflow Service Request"},"content":{"rendered":"<link rel='stylesheet' id='formidable-css' href='https:\/\/ems.hayeshandpiece.com.au\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=10262228' type='text\/css' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_handpiece-hotline\" id=\"frm_form_6_container\" data-token=\"2d9fac8da4173b67d9850711ad836622\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_js_validate  frm_ajax_submit  frm_pro_form  frm_logic_form \" id=\"form_emsrequest\" data-token=\"2d9fac8da4173b67d9850711ad836622\">\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_screen_reader\">Request EMS Airflow Service \/ Repair<\/legend>\r\n<h3 class=\"frm_form_title\">Request EMS Airflow Service \/ Repair<\/h3>\r\n<div class=\"frm_description\"><h4><strong style=\"background: #015699;padding: 1px 3px;color: #fff\">Before you book:<\/strong><\/h4>\n<p>Once you have completed this form, our team will confirm all details of your request and contact you with further instructions.<\/p>\n<p>If you have already requested an EMS Airflow Service \/ Repair, please don't complete this form again. We will provide you with a link to book your pickup once all details have been confirmed by Hayes.<\/p>\n<p>If you are sending any other small equipment items or handpieces, please use the <a href=\"https:\/\/trusted.my.site.com\/hayes\/login\" target=\"_blank\">Hayes Online Portal<\/a><\/p>\n<\/div><div class=\"frm_fields_container\">\n<div class=\"frm_rootline_group\" role=\"group\" tabindex=\"0\" aria-label=\"Page 1 of 5\" ><ul class=\"frm_page_bar frm_rootline_5 frm_progress frm_progress_line  frm_show_lines frm_show_titles\"><li class=\"frm_rootline_single frm_current_page\"><span class=\"frm_rootline_title\">Your Details<\/span><input type=\"button\" value=\"1\" data-page=\"\" class=\" frm_page_1\" aria-disabled=\"true\" data-field=\"0\" aria-label=\"Your Details\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Item Details<\/span><input type=\"button\" value=\"2\" data-page=\"21\" class=\"frm_page_skip frm_page_2\" data-field=\"211\" aria-label=\"Item Details\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Promotion Code<\/span><input type=\"button\" value=\"3\" data-page=\"106\" class=\"frm_page_skip frm_page_3\" data-field=\"534\" aria-label=\"Promotion Code\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Summary<\/span><input type=\"button\" value=\"4\" data-page=\"113\" class=\"frm_page_skip frm_page_4\" data-field=\"254\" aria-label=\"Summary\"  \/><\/li><li class=\"frm_rootline_single\"><span class=\"frm_rootline_title\">Submit Request<\/span><input type=\"button\" value=\"5\" data-page=\"119\" class=\"frm_page_skip frm_page_5\" data-field=\"273\" aria-label=\"Submit Request\"  \/><\/li><\/ul><div class=\"frm_percent_complete\">0% Complete<\/div><div class=\"frm_pages_complete\">1 of 5<\/div><div class=\"frm_clearfix\"><\/div><\/div><input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"6\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_6\" id=\"frm_hide_fields_6\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"emsrequest\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_6\" name=\"frm_submit_entry_6\" value=\"db54b29189\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php\/wp-json\/wp\/v2\/pages\/4907\" \/><input type=\"hidden\" name=\"item_meta[358]\" id=\"field_x5zup\" value=\"HPH2061EMS-[205]\"  data-frmval=\"HPH2061EMS-[205]\"   \/>\n<div id=\"frm_field_201_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Your Information<\/h3>\r\n\r\n\r\n<div id=\"frm_field_202_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_1yu1j3_label\" class=\"frm_primary_label\">Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_1yu1j3_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tName\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_202\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_202-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_1yu1j3_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tFirst\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_1yu1j3_first\" value=\"\" name=\"item_meta[202][first]\" data-sectionid=\"201\"  data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_202_first_desc\">First<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_202-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_1yu1j3_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tLast\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_1yu1j3_last\" value=\"\" name=\"item_meta[202][last]\" data-sectionid=\"201\"  data-reqmsg=\"Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Name is invalid\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_202_last_desc\">Last<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_203_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <label for=\"field_89eiq3\" id=\"field_89eiq3_label\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_89eiq3\" name=\"item_meta[203]\" value=\"\"  data-sectionid=\"201\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_conf_203_container\" class=\"frm_form_field frm_hidden_container frm_conf_field form-field  frm_required_field frm_top_container frm12 \">\r\n    <label for=\"field_conf_89eiq3\" id=\"field_conf_89eiq3_label\" class=\"frm_conf_label frm_primary_label\">Confirm Email\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_conf_89eiq3\" name=\"item_meta[conf_203]\" value=\"\"  data-sectionid=\"201\"  data-reqmsg=\"Confirm Email cannot be blank.\" aria-required=\"true\" data-confmsg=\"The entered values do not match\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_conf_89eiq3\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_conf_89eiq3\">Please confirm your email address.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_204_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <label for=\"field_pwdq93\" id=\"field_pwdq93_label\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_pwdq93\" name=\"item_meta[204]\" value=\"\"  data-sectionid=\"201\"  data-reqmsg=\"Phone cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_205_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_8k4hm3\" id=\"field_8k4hm3_label\" class=\"frm_primary_label\">Henry Schein Account Number\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_8k4hm3\" name=\"item_meta[205]\" value=\"\"  data-sectionid=\"201\"  data-reqmsg=\"Henry Schein Account Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_206_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_lx2t33\" id=\"field_lx2t33_label\" class=\"frm_primary_label\">Practice Name\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_lx2t33\" name=\"item_meta[206]\" value=\"\"  data-sectionid=\"201\"  data-reqmsg=\"Practice Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_208_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Practice Address<\/h3>\r\n\r\n\r\n<div id=\"frm_field_209_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <div  id=\"field_4mpqe3_label\" class=\"frm_primary_label\">Address\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_4mpqe3_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tAddress<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_209-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_4mpqe3_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_4mpqe3_line1\" value=\"\" name=\"item_meta[209][line1]\"  data-sectionid=\"208\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_209-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_4mpqe3_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tAddress\t<\/label>\n\t\t<input type=\"text\" id=\"field_4mpqe3_line2\" value=\"\" name=\"item_meta[209][line2]\"  data-sectionid=\"208\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_209-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_4mpqe3_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCity\t<\/label>\n\t\t<input type=\"text\" id=\"field_4mpqe3_city\" value=\"\" name=\"item_meta[209][city]\"  data-sectionid=\"208\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">City<\/div><\/div>\n<div id=\"frm_field_209-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_4mpqe3_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tState\t<\/label>\n\t\t<input type=\"text\" id=\"field_4mpqe3_state\" value=\"\" name=\"item_meta[209][state]\"  data-sectionid=\"208\"  data-reqmsg=\"Address cannot be blank.\" aria-required=\"true\" data-invmsg=\"Address is invalid\" aria-invalid=\"false\"   autocomplete=\"address-level1\" \/>\n\t<div class=\"frm_description\">State<\/div><\/div>\n<div id=\"frm_field_209-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_4mpqe3_zip\" class=\"frm_screen_reader 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Request EMS Airflow Service \/ Repair Before you book: Once you have completed this form, our team will confirm all details of your request and contact you with further instructions. If you have already requested an EMS Airflow Service \/ Repair, please don't complete this form again. We will [...]","protected":false},"author":6,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-4907","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/pages\/4907","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/comments?post=4907"}],"version-history":[{"count":3,"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/pages\/4907\/revisions"}],"predecessor-version":[{"id":7044,"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/pages\/4907\/revisions\/7044"}],"wp:attachment":[{"href":"https:\/\/ems.hayeshandpiece.com.au\/index.php\/wp-json\/wp\/v2\/media?parent=4907"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}