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In the UAE, daily life often involves walking on hard surfaces, long hours of standing, and exposure to extreme heat….
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<!– Note :
– You can modify the font style and form style to suit your website.
– Code lines with comments Do not remove this code are required for the form to work properly, make sure that you do not remove these lines of code.
– The Mandatory check script can modified as to suit your business needs.
– It is important that you test the modified form before going live.
– Do not remove captcha and other form elements that are necessary for the form to work. –>
<div id = ‘crmWebToEntityForm’ class = ‘zcwf_lblLeft crmWebToEntityForm’ style = ‘background-color: #F46C2F;color: black;max-width: 600px;’>
<meta name = ‘viewport’ content = ‘width=device-width, initial-scale=1.0’>
<META HTTP-EQUIV = ‘content-type’ CONTENT = ‘text/html;charset=UTF-8’>
<form id = ‘webform7326711000001014003’ action = ‘https://crm.zoho.com/crm/WebToLeadForm’ name = WebToLeads7326711000001014003 method = ‘POST’ onSubmit = ‘javascript:document.charset=”UTF-8″; return checkMandatory7326711000001014003()’ accept-charset = ‘UTF-8’>
<input type = ‘text’ style = ‘display:none;’ name = ‘xnQsjsdp’ value = ‘4b3b16d5aa2c8ab14756a8868c6d0e74054724a1ab76c21b9d1885ea9ae790dc’>
</input>
<input type = ‘hidden’ name = ‘zc_gad’ id = ‘zc_gad’ value = ”>
</input>
<input type = ‘text’ style = ‘display:none;’ name = ‘xmIwtLD’ value = ‘ecf28ce8901d1bbd96f0a28afbe4a426eb26845f1be90c7c9b2274fa5339b29224f327f736eb3db437aceb714629e856’>
</input>
<input type = ‘text’ style = ‘display:none;’ name = ‘actionType’ value = ‘TGVhZHM=’>
</input>
<input type = ‘text’ style = ‘display:none;’ name = ‘returnURL’ value = ‘https://www.lifebalance.ae/’>
</input>
<!– Do not remove this code. –>
<style>
html,body{
margin: 0px;
}
.formsubmit.zcwf_button{
color: white !important;
background: transparent linear-gradient(0deg, #0279FF 0%, #00A3F3 100%);
}
#crmWebToEntityForm.zcwf_lblLeft{
width: 100%;
padding: 25px;
margin: 0 auto;
box-sizing: border-box;
}
#crmWebToEntityForm.zcwf_lblLeft *{
box-sizing: border-box;
}
#crmWebToEntityForm{
text-align: left;
}
#crmWebToEntityForm *{
direction: ltr;
}
.zcwf_lblLeft .zcwf_title{
word-wrap: break-word;
padding: 0px 6px 10px;
font-weight: bold }
.zcwf_lblLeft.cpT_primaryBtn:hover{
background: linear-gradient(#02acff 0,#006be4 100%)no-repeat padding-box !important;
box-shadow: 0 -2px 0 0 #0159b9 inset !important;
border: 0 !important;
color: #fff !important;
outline: 0 !important;
}
.zcwf_lblLeft .zcwf_col_fld input[ type = text], input[ type = password], .zcwf_lblLeft .zcwf_col_fld textarea{
width: 60%;
border: 1px solid #c0c6cc !important;
resize: vertical;
border-radius: 2px;
float: left;
}
.zcwf_lblLeft .zcwf_col_lab{
width: 30%;
word-break: break-word;
padding: 0px 6px 0px;
margin-right: 10px;
margin-top: 5px;
float: left;
min-height: 1px;
}
.zcwf_lblLeft .zcwf_col_fld{
float: left;
width: 68%;
padding: 0px 6px 0px;
position: relative;
margin-top: 5px;
}
.zcwf_lblLeft .zcwf_privacy{
padding: 6px;
}
.zcwf_lblLeft .wfrm_fld_dpNn{
display: none;
}
.dIB{
display: inline-block;
}
.zcwf_lblLeft .zcwf_col_fld_slt{
width: 60%;
border: 1px solid #ccc;
background: #fff;
border-radius: 4px;
font-size: 12px;
float: left;
resize: vertical;
padding: 2px 5px;
}
.zcwf_lblLeft .zcwf_row:after, .zcwf_lblLeft .zcwf_col_fld:after{
content: ”;
display: table;
clear: both;
}
.zcwf_lblLeft .zcwf_col_help{
float: left;
margin-left: 7px;
font-size: 12px;
max-width: 35%;
word-break: break-word;
}
.zcwf_lblLeft .zcwf_help_icon{
cursor: pointer;
width: 16px;
height: 16px;
display: inline-block;
background: #fff;
border: 1px solid #c0c6cc;
color: #c1c1c1;
text-align: center;
font-size: 11px;
line-height: 16px;
font-weight: bold;
border-radius: 50%;
}
.zcwf_lblLeft .zcwf_row{
margin: 15px 0px;
}
.zcwf_lblLeft .formsubmit{
margin-right: 5px;
cursor: pointer;
color: #313949;
font-size: 12px;
}
.zcwf_lblLeft .zcwf_privacy_txt{
width: 90%;
color: rgb(0, 0, 0);
font-size: 12px;
font-family: Arial;
display: inline-block;
vertical-align: top;
color: #313949;
padding-top: 2px;
margin-left: 6px;
}
.zcwf_lblLeft .zcwf_button{
font-size: 12px;
color: #313949;
border: 1px solid #c0c6cc;
padding: 3px 9px;
border-radius: 4px;
cursor: pointer;
max-width: 120px;
overflow: hidden;
text-overflow: ellipsis;
white-space: nowrap;
}
.zcwf_lblLeft .zcwf_tooltip_over{
position: relative;
}
.zcwf_lblLeft .zcwf_tooltip_ctn{
position: absolute;
background: #dedede;
padding: 3px 6px;
top: 3px;
border-radius: 4px;
word-break: break-word;
min-width: 100px;
max-width: 150px;
color: #313949;
z-index: 100;
}
.zcwf_lblLeft .zcwf_ckbox{
float: left;
}
.zcwf_lblLeft .zcwf_file{
width: 55%;
box-sizing: border-box;
float: left;
}
.cBoth:after{
content: ”;
display: block;
clear: both;
}
@media all and (max-width: 600px){
.zcwf_lblLeft .zcwf_col_lab, .zcwf_lblLeft .zcwf_col_fld{
width: auto;
float: none !important;
}
.zcwf_lblLeft .zcwf_col_help{
width: 40%;
}
}
</style>
<div class = ‘zcwf_title’ style = ‘max-width: 600px;color: black; font-family:Arial;’>Customer Details</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ style = ‘font-size:12px; font-family: Arial;’>
<label for = ‘First_Name’>First Name
<span style = ‘color:red;’>*</span>
</label>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ id = ‘First_Name’ aria-required = ‘true’ aria-label = ‘First Name’ name = ‘First Name’ aria-valuemax = ’40’ maxlength = ’40’>
</input>
<div class = ‘zcwf_col_help’>
</div>
</div>
</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ style = ‘font-size:12px; font-family: Arial;’>
<label for = ‘Last_Name’>Last Name
<span style = ‘color:red;’>*</span>
</label>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ id = ‘Last_Name’ aria-required = ‘true’ aria-label = ‘Last Name’ name = ‘Last Name’ aria-valuemax = ’80’ maxlength = ’80’>
</input>
<div class = ‘zcwf_col_help’>
</div>
</div>
</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ style = ‘font-size:12px; font-family: Arial;’>
<label for = ‘Email’>Email
<span style = ‘color:red;’>*</span>
</label>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ ftype = ’email’ autocomplete = ‘false’ id = ‘Email’ aria-required = ‘true’ aria-label = ‘Email’ name = ‘Email’ aria-valuemax = ‘100’ crmlabel = ” maxlength = ‘100’>
</input>
<div class = ‘zcwf_col_help’>
</div>
</div>
</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ style = ‘font-size:12px; font-family: Arial;’>
<label for = ‘Phone’>Phone
<span style = ‘color:red;’>*</span>
</label>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ id = ‘Phone’ aria-required = ‘true’ aria-label = ‘Phone’ name = ‘Phone’ aria-valuemax = ’30’ maxlength = ’30’>
</input>
<div class = ‘zcwf_col_help’>
</div>
</div>
</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ style = ‘font-size:12px; font-family: Arial;’>
<label for = ‘Address_-_City’>Address – City</label>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ id = ‘Address_-_City’ aria-required = ‘false’ aria-label = ‘Address – City’ name = ‘Address – City’ aria-valuemax = ‘255’ maxlength = ‘255’>
</input>
<div class = ‘zcwf_col_help’>
</div>
</div>
</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ style = ‘font-size:12px; font-family: Arial;’>
<label for = ‘Address_-_Street_Address’>Address – Street Address</label>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ id = ‘Address_-_Street_Address’ aria-required = ‘false’ aria-label = ‘Address – Street Address’ name = ‘Address – Street Address’ aria-valuemax = ‘255’ maxlength = ‘255’>
</input>
<div class = ‘zcwf_col_help’>
</div>
</div>
</div>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’ id = ‘reCaptchaField’ style = ‘font-size:12px; font-family: Arial;’>Enter the Captcha</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘text’ id = ‘captchaField7326711000001014003’ aria-labelledby = ‘reCaptchaField’ aria-valuemax = ’10’ maxlength = ’10’ name = ‘enterdigest’/>
<div id = ‘captchaErr7326711000001014003’ aria-live = ‘polite’ style = ‘font-size:14px;color:red;padding-left:1px;visibility:hidden;position:absolute;padding-top:25px;’>
</div>
</div>
</div>
<!– Do not remove this code. –>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’>
</div>
<div class = ‘zcwf_col_fld’>
<img id = ‘imgid7326711000001014003’ src = ‘https://crm.zoho.com/crm/CaptchaServlet?formId=ecf28ce8901d1bbd96f0a28afbe4a426eb26845f1be90c7c9b2274fa5339b29224f327f736eb3db437aceb714629e856&grpid=4b3b16d5aa2c8ab14756a8868c6d0e74054724a1ab76c21b9d1885ea9ae790dc’>
<a href = ‘javascript:;’ onclick = ‘reloadImg7326711000001014003();’>Reload</a>
</div>
<div class = ”>
</div>
</div>
<input type = ‘text’ type = ‘hidden’ style = ‘display: none;’ name = ‘aG9uZXlwb3Q’ value = ”/>
<div class = ‘zcwf_row’>
<div class = ‘zcwf_col_lab’>
</div>
<div class = ‘zcwf_col_fld’>
<input type = ‘submit’ id = ‘formsubmit’ role = ‘button’ class = ‘formsubmit zcwf_button’ value = ‘Submit’ aria-label = ‘Submit’ title = ‘Submit’>
<input type = ‘reset’ class = ‘zcwf_button’ role = ‘button’ name = ‘reset’ value = ‘Reset’ aria-label = ‘Reset’ title = ‘Reset’>
</div>
</div>
<script>
/* Do not remove this code. */
function reloadImg7326711000001014003(){
var captcha = document.getElementById(‘imgid7326711000001014003’);
if (captcha.src.indexOf (‘&d’) !== -1) {
captcha.src = captcha.src.substring(0, captcha.src.indexOf(‘&d’)) + ‘&d’ + new Date().getTime();
} else {
captcha.src = captcha.src + ‘&d’ + new Date().getTime();
}
}
function historyBack7326711000001014003(){
document.querySelector(‘.crmWebToEntityForm .formsubmit’).removeAttribute(‘disabled’);
reloadImg7326711000001014003();
window.removeEventListener(‘focus’, historyBack7326711000001014003);
}
function validateEmail7326711000001014003(){
var form = document.forms[‘WebToLeads7326711000001014003’];
var emailFld = form.querySelectorAll(‘[ftype=email]’);
var i;
for(i = 0; i < emailFld.length; i++ ) {
var emailVal = emailFld[i].value;
if ((emailVal.replace (/^\s+|\s+$/g,”) ) .length != 0) {
var atpos = emailVal.indexOf(‘@’);
var dotpos = emailVal.lastIndexOf(‘.’);
if(atpos < 1 || dotpos < atpos + 2 || dotpos + 2 >= emailVal.length) {
alert(‘Please enter a valid email address. ‘);
emailFld[i].focus();
return false;
}
}
}
return true;
}
function checkMandatory7326711000001014003(isAjax){
var mndFileds = new Array(‘First Name’, ‘Last Name’, ‘Email’, ‘Phone’);
var fldLangVal = new Array(‘First Name’, ‘Last Name’, ‘Email’, ‘Phone’);
for (i = 0; i < mndFileds.length; i++ ) {
var fieldObj = document.forms[‘WebToLeads7326711000001014003’] [mndFileds[i]];
if (fieldObj) {
if(((fieldObj.value) .replace (/^\s+|\s+$/g,”) ) .length == 0) {
if (fieldObj.type == ‘file’) {
alert(‘Please select a file to upload.’);
fieldObj.focus();
return false;
}
alert(fldLangVal[i] + ‘ cannot be empty.’);
fieldObj.focus();
return false;
} else if (fieldObj.nodeName == ‘SELECT’) {
if (fieldObj.options[fieldObj.selectedIndex].value == ‘-None-‘) {
alert(fldLangVal[i] + ‘ cannot be none.’);
fieldObj.focus();
return false;
}
} else if (fieldObj.type == ‘checkbox’) {
if (fieldObj.checked == false) {
alert(‘Please accept ‘ + fldLangVal[i]);
fieldObj.focus();
return false;
}
}
try{
if (fieldObj.name == ‘Last Name’) {
name = fieldObj.value;
}
} catch (e){}
}
}
if ( !validateEmail7326711000001014003 () ) {
return false;
}
var urlparams = new URLSearchParams(window.location.search);
if (urlparams.has (‘service’) && (urlparams.get (‘service’) === ‘smarturl’) ) {
var webform = document.getElementById(‘webform7326711000001014003’);
var service = urlparams.get(‘service’);
var smarturlfield = document.createElement(‘input’);
smarturlfield.setAttribute(‘type’, ‘hidden’);
smarturlfield.setAttribute(‘value’, service);
smarturlfield.setAttribute(‘name’, ‘service’);
webform.appendChild(smarturlfield);
}
document.querySelector(‘.crmWebToEntityForm .formsubmit’).setAttribute(‘disabled’, true);
if ( !isAjax) {
window.addEventListener(‘focus’, historyBack7326711000001014003);
}
}
function tooltipShow7326711000001014003(el){
var tooltip = el.nextElementSibling;
var tooltipDisplay = tooltip.style.display;
if (tooltipDisplay == ‘none’) {
var allTooltip = document.getElementsByClassName(‘zcwf_tooltip_over’);
for (i = 0; i < allTooltip.length; i++ ) {
allTooltip[i].style.display = ‘none’;
}
tooltip.style.display = ‘block’;
} else {
tooltip.style.display = ‘none’;
}
}
</script>
<!– Do not remove this — Analytics Tracking code starts –>
<script id = ‘wf_anal’ src = ‘https://crm.zohopublic.com/crm/WebFormAnalyticsServeServlet?rid=bbf4fff95bbf48e3678b0ec6608764c1d5adae5799615d8b7f3602e01c72ae9ed29dfb90d576d4c3306609bf3efa3c64gid14372de2d175595423335d8e7becb79f0fcca893e2b3d80695c3b3a9ce2c22bdgid58f82f6b8528346e329177e908ec9861272efb04a5d1e23f5b6b19b06f1fc142gidf7d9771980946f453f40eda280836c8678eed7bfb444e66151a3b157231f24a5&tw=a0c8b19543a721c522c8459ac104f1ef6fb1c2b2ec06df6786b31a70d08e2308’>
</script>
<!– Do not remove this — Analytics Tracking code ends. –>
</form>
<!– Do not remove this code. –>
<iframe name = ‘captchaFrame’ style = ‘display:none;’>
</iframe>
</div>
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