{"id":334,"date":"2023-03-24T09:07:16","date_gmt":"2023-03-24T16:07:16","guid":{"rendered":"https:\/\/www.empirevein.com\/?page_id=334"},"modified":"2026-05-22T09:04:04","modified_gmt":"2026-05-22T16:04:04","slug":"book-online","status":"publish","type":"page","link":"https:\/\/empirevein.com\/en\/book-online\/","title":{"rendered":"Book a Vein Screening"},"content":{"rendered":"<style>.kb-row-layout-id334_812b52-1f > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id334_812b52-1f > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id334_812b52-1f > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);padding-top:var(--global-kb-spacing-sm, 1.5rem);padding-bottom:0px;grid-template-columns:repeat(2, minmax(0, 1fr));}.kb-row-layout-id334_812b52-1f > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id334_812b52-1f > .kt-row-column-wrap{grid-template-columns:repeat(2, minmax(0, 1fr));}}@media all and (max-width: 767px){.kb-row-layout-id334_812b52-1f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id334_812b52-1f alignnone wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-2-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column334_31a104-95 > .kt-inside-inner-col{display:flex;}.kadence-column334_31a104-95 > .kt-inside-inner-col,.kadence-column334_31a104-95 > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column334_31a104-95 > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column334_31a104-95 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}.kadence-column334_31a104-95 > .kt-inside-inner-col > .aligncenter{width:100%;}.kt-row-column-wrap > .kadence-column334_31a104-95{align-self:flex-start;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column334_31a104-95{align-self:auto;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column334_31a104-95 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}.kadence-column334_31a104-95 > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column334_31a104-95{position:relative;}@media all and (max-width: 1024px){.kt-row-column-wrap > .kadence-column334_31a104-95{align-self:flex-start;}}@media all and (max-width: 1024px){.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column334_31a104-95{align-self:auto;}}@media all and (max-width: 1024px){.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column334_31a104-95 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}}@media all and (max-width: 1024px){.kadence-column334_31a104-95 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}}@media all and (max-width: 767px){.kt-row-column-wrap > .kadence-column334_31a104-95{align-self:flex-start;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column334_31a104-95{align-self:auto;}.kt-inner-column-height-full:not(.kt-has-1-columns) > .wp-block-kadence-column.kadence-column334_31a104-95 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}.kadence-column334_31a104-95 > .kt-inside-inner-col{flex-direction:column;justify-content:flex-start;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column334_31a104-95\"><div class=\"kt-inside-inner-col\">\n<h4 id=\"we-offer-free-vein-screenings-at-any-of-our-conveniently-located-offices\" class=\"wp-block-heading\">We offer free vein screenings at any of our conveniently located offices.<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Expert Vein Care Specialists<\/li>\n\n\n\n<li>Most treatments covered by insurance<\/li>\n\n\n\n<li>Personalized care and follow-up<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">To book your vein screening, complete this form and we will contact you shortly.<\/p>\n<\/div><\/div>\n\n\n<style>.kadence-column334_981e86-dd > .kt-inside-inner-col,.kadence-column334_981e86-dd > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column334_981e86-dd > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column334_981e86-dd > .kt-inside-inner-col{flex-direction:column;}.kadence-column334_981e86-dd > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column334_981e86-dd > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column334_981e86-dd{position:relative;}@media all and (max-width: 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The minimum is\"});\n\t\/*INIT-END*\/\n\t});\n\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,null,{\"name\":\"submit\",\"qid\":\"2\",\"text\":\"SUBMIT\",\"type\":\"control_button\"},null,null,{\"name\":\"typeA5\",\"qid\":\"5\",\"text\":\"\",\"type\":\"control_widget\"},null,null,{\"description\":\"\",\"name\":\"firstName\",\"qid\":\"8\",\"subLabel\":\"\",\"text\":\"First Name *\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"lastName\",\"qid\":\"9\",\"subLabel\":\"\",\"text\":\"Last Name *\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"email\",\"qid\":\"10\",\"subLabel\":\"\",\"text\":\"Email *\",\"type\":\"control_email\"},null,{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"12\",\"text\":\"Phone *\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"haveYou\",\"qid\":\"13\",\"subLabel\":\"\",\"text\":\"Have You Scheduled An Appointment With Us Before? *\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"isNewText\",\"qid\":\"14\",\"subLabel\":\"\",\"text\":\"LIINE IS NEW\",\"type\":\"control_textbox\"},null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"chooseYour\",\"qid\":\"26\",\"subLabel\":\"\",\"text\":\"Preferred Location *\",\"type\":\"control_dropdown\"},null,null,{\"name\":\"typeA\",\"qid\":\"29\",\"text\":\"Get Page URL\",\"type\":\"control_widget\"},null,null,null,{\"description\":\"\",\"name\":\"liineRedirect\",\"qid\":\"33\",\"subLabel\":\"\",\"text\":\"LIINE REDIRECT\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"preferredLanguage\",\"qid\":\"34\",\"subLabel\":\"\",\"text\":\"Preferred Language *\",\"type\":\"control_dropdown\"},null,{\"description\":\"\",\"name\":\"liineLocation\",\"qid\":\"36\",\"subLabel\":\"\",\"text\":\"LIINE LOCATION\",\"type\":\"control_textbox\"},{\"description\":\"\",\"mde\":\"No\",\"name\":\"message\",\"qid\":\"37\",\"subLabel\":\"\",\"text\":\"Message\",\"type\":\"control_textarea\",\"wysiwyg\":\"Disable\"},null,{\"description\":\"\",\"name\":\"typeA39\",\"qid\":\"39\",\"text\":\"\",\"type\":\"control_checkbox\"},{\"description\":\"\",\"name\":\"phoneCondition\",\"qid\":\"40\",\"subLabel\":\"\",\"text\":\"Phone Condition\",\"type\":\"control_textbox\"},{\"name\":\"input41\",\"qid\":\"41\",\"text\":\"Oops! It looks like the phone number you input is invalid. Please input a valid phone number in order to submit.\",\"type\":\"control_text\"}]);}, 20); \n<\/script>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/forms.liine.com\/stylebuilder\/static\/form-common.css?v=60a7156\n\">\n<style type=\"text\/css\">@media print{*{-webkit-print-color-adjust: exact !important;color-adjust: exact !important;}.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}<\/style>\n<link id=\"custom-font\" type=\"text\/css\" rel=\"stylesheet\" href=\"\/\/cdn.jotfor.ms\/fonts\/?family=Roboto|Inter\">\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/forms.liine.com\/themes\/CSS\/5e6b428acc8c4e222d1beb91.css?v=3.3.68652&amp;themeRevisionID=5eb3b4ae85bd2e1e2966db96\">\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"\/s\/static\/a044de57fa4\/css\/styles\/payment\/payment_styles.css?3.3.68652\">\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"\/s\/static\/a044de57fa4\/css\/styles\/payment\/payment_feature.css?3.3.68652\">\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n\n\/* Begining of advanced designer *\/\n\n\/* 17 - INPUT WIDTHS *\/\n\/*  20 - FORM PADDING *\/\nul.form-section {\n  padding: 0px 38px;\n}\n.form-textbox:not(#productSearch-input),\n.form-textarea,\nli[data-type=control_fileupload] .qq-upload-button,\n.signature-wrapper {\n  border-color: #bebebe;\n  color: #000000;\n}\n.form-textarea:hover,\n.form-textbox:hover,\nli[data-type=control_fileupload] .qq-upload-button:hover,\n.signature-wrapper:hover {\n  border-color: rgba(190, 190, 190, 0.5);\n  box-shadow: 0 0 0 2px rgba(190, 190, 190, 0.25);\n}\n.form-textarea:focus,\n.form-textbox:focus,\nli[data-type=control_fileupload] .qq-upload-button:focus,\n.signature-wrapper:focus {\n  border-color: #bebebe;\n  box-shadow: 0 0 0 3px rgba(190, 190, 190, 0.25);\n}\n\/* Heights *\/\n.form-textbox {\n  height: 40px;\n}\n.form-textarea {\n  height: 105px !important;\n}\nli[data-type=\"control_textbox\"] div[data-layout=\"half\"],\nli[data-type=\"control_dropdown\"] div[data-layout=\"half\"],\nli[data-type=\"control_email\"] div[data-layout=\"half\"],\nli[data-type=\"control_number\"] div[data-layout=\"half\"],\nli[data-type=\"control_phone\"] div[data-layout=\"half\"],\nli[data-type=\"control_datetime\"] div[data-layout=\"half\"] {\n  width: 100% !important;\n  max-width: 1000px;\n}\nli[data-type=\"control_textarea\"] div[data-layout=\"full\"],\nli[data-type=\"control_fullname\"] div[data-layout=\"full\"],\nli[data-type=\"control_matrix\"] div[data-layout=\"full\"],\nli[data-type=\"control_address\"] div[data-layout=\"full\"],\nli[data-type=\"control_fileupload\"] div[data-layout=\"full\"],\nli[data-type=\"control_appointment\"] div[data-layout=\"full\"] {\n  width: 100% !important;\n  max-width: 1000px;\n}\n.form-label {\n  margin-bottom: 6px;\n  margin-right: 0;\n}\n\/* 11 - LINE PADDING *\/\n.form-line {\n  padding: 3px 3px;\n}\n\/* LABEL STYLE *\/\n.form-dropdown:first-child {\n  border-width: 1px;\n  border-color: #bebebe;\n  color: #000000;\n  background-color: #ffffff;\n  height: 40px;\n}\n[data-type=\"control_dropdown\"] .form-input,\n[data-type=\"control_birthdate\"] .form-input,\n[data-type=\"control_time\"] .form-input,\n[data-type=\"control_dropdown\"] .form-input-wide,\n[data-type=\"control_birthdate\"] .form-input-wide,\n[data-type=\"control_time\"] .form-input-wide {\n  width: 100% !important;\n  max-width: 900px;\n}\n[data-type=\"control_dropdown\"] .form-dropdown {\n  width: 100% !important;\n  max-width: 900px;\n}\n\/* 12 - ROUNDED INPUTS *\/\n.form-textbox:not(#productSearch-input),\n.form-radio-other-input,\n.form-checkbox-other-input,\n.form-captcha input,\n.form-spinner input,\n.form-pagebreak-back,\n.form-pagebreak-next,\n.qq-upload-button,\n.signature-wrapper,\n.form-error-message {\n  border-radius: 6px;\n}\n.form-textarea {\n  border-radius: 6px;\n  padding: 10px;\n}\n.form-dropdown {\n  border-radius: 6px;\n  appearance: none;\n  margin: 0;\n}\n.form-radio-item,\n.form-checkbox-item {\n  padding-bottom: 0px;\n}\n.form-radio-item:last-child,\n.form-checkbox-item:last-child {\n  padding-bottom: 0;\n}\n.form-checkbox-item .form-checkbox + label,\n.form-checkbox-item .form-checkbox + span {\n  padding-left: 30px;\n}\n.form-radio-item .form-radio + label,\n.form-radio-item .form-radio + span {\n  padding-left: 30px;\n}\n.form-single-column .form-checkbox-item,\n.form-single-column .form-radio-item {\n  width: 100%;\n}\n.form-checkbox-item .editor-container div,\n.form-radio-item .editor-container div {\n  position: relative;\n}\n.form-checkbox-item .editor-container div:before,\n.form-radio-item .editor-container div:before {\n  display: inline-block;\n  vertical-align: middle;\n  left: 0;\n  width: 20px;\n  height: 20px;\n}\n.form-checkbox-item input,\n.form-radio-item input {\n  margin-top: 2px;\n}\n.form-checkbox:checked + label:before,\n.form-checkbox:checked + span:before {\n  background-color: #2e69ff;\n  border-color: #2e69ff;\n}\n.form-radio:checked + label:before,\n.form-radio:checked + span:before {\n  border-color: #2e69ff;\n}\n.form-radio:checked + label:after,\n.form-radio:checked + span:after {\n  background-color: #2e69ff;\n}\n.form-checkbox:hover + label:before,\n.form-checkbox:hover + span:before,\n.form-radio:hover + label:before,\n.form-radio:hover + span:before {\n  border-color: rgba(46, 105, 255, 0.5);\n  box-shadow: 0 0 0 2px rgba(46, 105, 255, 0.25);\n}\n.form-checkbox:focus + label:before,\n.form-checkbox:focus + span:before,\n.form-radio:focus + label:before,\n.form-radio:focus + span:before {\n  border-color: #2e69ff;\n  box-shadow: 0 0 0 3px rgba(46, 105, 255, 0.25);\n}\n.submit-button {\n  font-size: 16px;\n  font-weight: bold;\n  font-family: inherit;\n  height: 45px;\n  width: 750px;\n  border: none;\n  border-width: 1px;\n  border-style: solid;\n  border-color: #ef662f;\n}\n.submit-button {\n  font-family: \"Inter\", sans-serif;\n}\n.submit-button {\n  min-width: 180px;\n}\nli[data-type=\"control_button\"] .form-submit-button {\n  color: #ffffff;\n  background-color: #ef662f;\n  background-image: none;\n  box-shadow: none;\n  text-shadow: none;\n}\nli[data-type=\"control_button\"] .form-submit-button:hover {\n  background-color: #ab3a0d;\n}\nli[data-type=\"control_button\"] button.jf-form-buttons.form-sacl-button,\nli[data-type=\"control_button\"] button.jf-form-buttons.form-submit-print {\n  color: #ef662f;\n  border-color: #ef662f;\n  background-image: none;\n  background-color: #fff;\n}\nli[data-type=\"control_button\"] button.jf-form-buttons.form-sacl-button:hover,\nli[data-type=\"control_button\"] button.jf-form-buttons.form-submit-print:hover {\n  background-color: #ab3a0d;\n  color: #fff;\n}\nli[data-type=\"control_button\"] button.jf-form-buttons.form-pagebreak-back {\n  background-image: none;\n  background-color: #ab3a0d;\n  box-shadow: none;\n  text-shadow: none;\n}\nli[data-type=\"control_button\"] button.jf-form-buttons.form-pagebreak-back:hover {\n  background-color: #7c2a09;\n  color: #fff;\n}\n.form-submit-button,\n.form-submit-reset,\n.form-submit-print {\n  border-radius: 100px;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  font-family: \"Roboto\", sans-serif;\n  font-size: 15px;\n  font-weight: normal;\n}\n.form-all .form-pagebreak-back,\n.form-all .form-pagebreak-next {\n  min-width: 128px;\n}\nli[data-type=\"control_image\"] div {\n  text-align: left;\n}\nli[data-type=\"control_image\"] img {\n  border: none;\n  border-width: 0px !important;\n  border-style: solid !important;\n  border-color: false !important;\n}\n.supernova {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-attachment: fixed;\n  background-size: auto;\n  background-size: cover;\n}\n.supernova {\n  background-image: none;\n}\n#stage {\n  background-image: none;\n}\n\/* | *\/\n.form-all {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n  background-size: cover;\n}\n.form-header-group {\n  background-repeat: no-repeat;\n  background-attachment: scroll;\n  background-position: center top;\n}\n.header-large h1.form-header {\n  font-size: 2em;\n}\n.header-large h2.form-header {\n  font-size: 1.5em;\n}\n.header-large h3.form-header {\n  font-size: 1.17em;\n}\n.header-large h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-large h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-large h3 + .form-subHeader {\n  font-size: .75em;\n}\n.header-default h1.form-header {\n  font-size: 2em;\n}\n.header-default h2.form-header {\n  font-size: 1.5em;\n}\n.header-default h3.form-header {\n  font-size: 1.17em;\n}\n.header-default h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-default h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-default h3 + .form-subHeader {\n  font-size: .75em;\n}\n.header-small h1.form-header {\n  font-size: 2em;\n}\n.header-small h2.form-header {\n  font-size: 1.5em;\n}\n.header-small h3.form-header {\n  font-size: 1.17em;\n}\n.header-small h1 + .form-subHeader {\n  font-size: 1em;\n}\n.header-small h2 + .form-subHeader {\n  font-size: .875em;\n}\n.header-small h3 + .form-subHeader {\n  font-size: .75em;\n}\n.form-header-group {\n  text-align: left;\n}\ndiv.form-header-group.header-large,\ndiv.form-header-group.hasImage {\n  margin: 0px -38px;\n}\ndiv.form-header-group.header-large,\ndiv.form-header-group.hasImage {\n  padding: 40px 52px;\n}\n.form-header-group .form-header,\n.form-header-group .form-subHeader {\n  color: -1;\n}\n.form-line-error {\n  background-color: rgba(195, 202, 216, 0.3);\n  box-shadow: inset 0px 3px 11px -7px rgba(255, 255, 255, 0);\n}\n.form-line-error input:not(#coupon-input),\n.form-line-error textarea,\n.form-line-error .form-validation-error {\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  border: 1px solid rgba(255, 255, 255, 0);\n  box-shadow: 0 0 3px rgba(255, 255, 255, 0);\n}\n.form-line-error .form-error-message {\n  margin: 0;\n  position: absolute;\n  color: #fff;\n  display: inline-block;\n  right: 0;\n  font-size: 12px;\n  position: absolute!important;\n  box-shadow: none;\n  top: 0px;\n  color: #FFF;\n  background: rgba(255, 255, 255, 0);\n  padding: 0px 5px;\n  bottom: auto;\n  border-radius: 0;\n  box-shadow: 0px 2px 4px rgba(102, 102, 102, 0.5);\n}\n.form-line-error .form-error-message img,\n.form-line-error .form-error-message .form-error-arrow {\n  display: none;\n}\n.form-line-error {\n  -webkit-transition-property: none;\n  -moz-transition-property: none;\n  -ms-transition-property: none;\n  -o-transition-property: none;\n  transition-property: none;\n  -webkit-transition-duration: 0.3s;\n  -moz-transition-duration: 0.3s;\n  -ms-transition-duration: 0.3s;\n  -o-transition-duration: 0.3s;\n  transition-duration: 0.3s;\n  -webkit-transition-timing-function: ease;\n  -moz-transition-timing-function: ease;\n  -ms-transition-timing-function: ease;\n  -o-transition-timing-function: ease;\n  transition-timing-function: ease;\n  background-color: rgba(255, 255, 255, 0);\n}\n.form-line-active {\n  background-color: rgba(255, 255, 255, 0);\n}\n\/* 29 - FORM COLUMNS *\/\n.form-line-column {\n  width: calc(100\/2 * 1% - 8px);\n}\n\n\/*PREFERENCES STYLE*\/\n    .form-all {\n      font-family: Roboto, sans-serif;\n    }\n  \n    .form-label.form-label-auto {\n      \n    display: block;\n    float: none;\n    text-align: left;\n    width: 100%;\n  \n    }\n  \n    .form-line {\n      margin-top: 4px;\n      margin-bottom: 4px;\n    }\n  \n    .form-all {\n      max-width: 750px;\n      width: 100%;\n    }\n  \n    .form-label.form-label-left,\n    .form-label.form-label-right,\n    .form-label.form-label-left.form-label-auto,\n    .form-label.form-label-right.form-label-auto {\n      width: 230px;\n    }\n  \n    .form-all {\n      font-size: 15px\n    }\n  \n    .supernova .form-all, .form-all {\n      background-color: rgba(195, 202, 216, 0.3);\n    }\n  \n    .form-all {\n      color: #000000;\n    }\n    .form-header-group .form-header {\n      color: #000000;\n    }\n    .form-header-group .form-subHeader {\n      color: #000000;\n    }\n    .form-label-top,\n    .form-label-left,\n    .form-label-right,\n    .form-html,\n    .form-checkbox-item label,\n    .form-radio-item label,\n    span.FITB .qb-checkbox-label,\n    span.FITB .qb-radiobox-label,\n    span.FITB .form-radio label,\n    span.FITB .form-checkbox label,\n    [data-blotid][data-type=checkbox] [data-labelid],\n    [data-blotid][data-type=radiobox] [data-labelid],\n    span.FITB-inptCont[data-type=checkbox] label,\n    span.FITB-inptCont[data-type=radiobox] label {\n      color: #000000;\n    }\n    .form-sub-label {\n      color: #1a1a1a;\n    }\n  \n  .supernova {\n    background-color: rgba(255,255,255,0);\n  }\n  .supernova body {\n    background: transparent;\n  }\n  \n    .form-textbox,\n    .form-textarea,\n    .form-dropdown,\n    .form-radio-other-input,\n    .form-checkbox-other-input,\n    .form-captcha input,\n    .form-spinner input {\n      background-color: rgb(255, 255, 255);\n    }\n  \n      \n    .supernova {\n      background-repeat: no-repeat;\n      background-size:cover;\n      background-attachment: fixed;\n      background-position: center top;\n    }\n\n      .supernova, #stage {\n        background-image: none;\n      }\n    \n      .form-all {\n        background-image: none;\n      }\n    \/*PREFERENCES STYLE*\/\/*__INSPECT_SEPERATOR__*\/\n.form-buttons-wrapper {\n    border-top : 0;\n    margin-bottom : -20px;\n}\n\n.form-all {\n    box-shadow : none !important;\n}\n\n.error-navigation-container {\n    display : none;\n}\n\n.form-error-message {\n    display : none;\n}\n\n.form-required {\n    display : none !important;\n}\n\n.form-label {\n    color : #515459 !important;\n}\n\n.form-validation-error {\n    border : 1px solid #bebebe !important;\n}\n\n.form-error-message {\n    background-color : #ef662f !important;\n}\n\n.supernova .form-all, .form-all {\n    margin-top : 0px !important;\n}\n\n\n    \/* Injected CSS Code *\/\n<\/style>\n\n<form class=\"jotform-form\" onsubmit=\"return typeof testSubmitFunction !== 'undefined' &amp;&amp; testSubmitFunction();\" action=\"https:\/\/forms.liine.com\/submit\/242175241542955\" method=\"post\" name=\"form_242175241542955\" id=\"242175241542955\" accept-charset=\"utf-8\" autocomplete=\"on\"><input type=\"hidden\" name=\"formID\" value=\"242175241542955\"><input type=\"hidden\" id=\"JWTContainer\" value=\"\"><input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\"><input type=\"hidden\" id=\"jsExecutionTracker\" name=\"jsExecutionTracker\" value=\"build-date-1770306094584\"><input type=\"hidden\" id=\"submitSource\" name=\"submitSource\" value=\"unknown\"><input type=\"hidden\" id=\"submitDate\" name=\"submitDate\" value=\"undefined\"><input type=\"hidden\" id=\"buildDate\" name=\"buildDate\" value=\"1770306094584\"><input type=\"hidden\" name=\"uploadServerUrl\" value=\"https:\/\/upload.jotform.com\/upload\"><input type=\"hidden\" name=\"eventObserver\" value=\"1\">\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\" role=\"presentation\">\n  <h2 class=\"form-heading\">Book a Free Vein Screening<br> with No Obligation<\/h2>\n      <li class=\"form-line\" data-type=\"control_widget\" id=\"id_5\">\n        <div id=\"cid_5\" class=\"form-input\" data-layout=\"full\">\n          <div data-widget-name=\"Liine GUID Injector\" style=\"width:100%;text-align:Left;overflow-x:auto\" data-component=\"widget-field\"><iframe data-client-id=\"ef8be44c2da136d2f81e916e\" data-unique-id=\"\" title=\"Liine GUID Injector\" frameborder=\"0\" scrolling=\"no\" allowtransparency=\"true\" allow=\"geolocation; microphone; camera; autoplay; encrypted-media; fullscreen\" data-type=\"iframe\" class=\"custom-field-frame\" data-widget-slug=\"\" id=\"customFieldFrame_5\" src=\"\" style=\"max-width:1px;border:none;width:100%;height:1px\" data-width=\"1\" data-height=\"1\"><\/iframe>\n            <div class=\"widget-inputs-wrapper\"><input id=\"input_5\" class=\"form-hidden form-widget  \" type=\"hidden\" name=\"q5_typeA5\" value=\"\"><input id=\"widget_settings_5\" class=\"form-hidden form-widget-settings\" type=\"hidden\" data-version=\"2\" value=\"%5B%5D\"><\/div>\n            <script type=\"text\/javascript\">\n              setTimeout(function()\n              {\n                function renderWidget()\n                {\n                  var _cFieldFrame = document.getElementById(\"customFieldFrame_5\");\n                  if (_cFieldFrame)\n                  {\n                    _cFieldFrame.onload = function()\n                    {\n                      if (typeof widgetFrameLoaded !== 'undefined')\n                      {\n                        widgetFrameLoaded(5,\n                        {\n                          \"formID\": 242175241542955\n                        }, undefined,\n                        {})\n                      }\n                    };\n                    _cFieldFrame.src = \"\/\/analytics.liine.com\/v1\/jotform_widget.html?qid=5&isOpenedInPortal=undefined&isOpenedInAgent=undefined&align=Left&ref=\" +\n                      encodeURIComponent(window.location.protocol + \"\/\/\" + window.location.host) + '' + '' + '' +\n                      '&injectCSS=' + encodeURIComponent(window.location.search.indexOf(\"ndt=1\") > -1);\n                    _cFieldFrame.addClassName(\"custom-field-frame-rendered\");\n                  }\n                }\n                if (false)\n                {\n                  var _interval = setInterval(function()\n                  {\n                    var dataMode = document.querySelector('html').getAttribute('data-mode');\n                    if (dataMode === 'fillMode')\n                    {\n                      renderWidget()\n                      clearInterval(_interval);\n                    }\n                  }, 1000);\n                }\n                else\n                {\n                  renderWidget();\n                }\n              }, 0);\n            <\/script>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_textbox\" id=\"id_8\"><label class=\"form-label form-label-top\" id=\"label_8\" for=\"input_8\" aria-hidden=\"false\"> First Name *<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_8\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_8\" name=\"q8_firstName\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_8\" aria-describedby=\"input_8-description\" required=\"\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_textbox\" id=\"id_9\"><label class=\"form-label form-label-top\" id=\"label_9\" for=\"input_9\" aria-hidden=\"false\"> Last Name *<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"text\" id=\"input_9\" name=\"q9_lastName\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_9\" aria-describedby=\"input_9-description\" required=\"\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_email\" id=\"id_10\"><label class=\"form-label form-label-top\" id=\"label_10\" for=\"input_10\" aria-hidden=\"false\"> Email *<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <input type=\"email\" id=\"input_10\" name=\"q10_email\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" autocomplete=\"section-input_10 email\" style=\"width:310px\" size=\"310\" data-component=\"email\" aria-labelledby=\"label_10\" aria-describedby=\"input_10-description\" required=\"\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4 jf-required\" data-type=\"control_phone\" id=\"id_12\"><label class=\"form-label form-label-top\" id=\"label_12\" for=\"input_12_full\"> Phone *<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"tel\" id=\"input_12_full\" name=\"q12_phoneNumber[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[required, Fill Mask]\" data-defaultvalue=\"\" autocomplete=\"section-input_12 tel-national\" style=\"width:310px\" data-masked=\"true\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_12\" aria-describedby=\"input_12-description\" required=\"\" value=\"\"><\/span> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_26\"><label class=\"form-label form-label-top\" id=\"label_26\" for=\"input_26\" aria-hidden=\"false\"> Preferred Location *<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_26\" class=\"form-input-wide jf-required\" data-layout=\"half\"> <select class=\"form-dropdown validate[required]\" id=\"input_26\" name=\"q26_chooseYour\" style=\"width:310px\" data-component=\"dropdown\" required=\"\" aria-label=\"Preferred Location *\">\n            <option value=\"\">Please Select<\/option>\n            <option data-calcvalue=\"Riverside, CA\" value=\"Riverside\">Riverside<\/option>\n            <option data-calcvalue=\"Ontario, CA\" value=\"Ontario\">Ontario<\/option>\n            <option data-calcvalue=\"Victorville, CA\" value=\"Victorville\">Victorville<\/option>\n            <option data-calcvalue=\"Rancho Mirage, CA\" value=\"Rancho Mirage\">Rancho Mirage<\/option>\n            <option data-calcvalue=\"Palm Springs, CA\" value=\"Palm Springs\">Palm Springs<\/option>\n            <option data-calcvalue=\"La Quinta, CA\" value=\"La Quinta\">La Quinta<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_textbox\" id=\"id_36\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_36\" for=\"input_36\" aria-hidden=\"false\"> LIINE LOCATION <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <input type=\"text\" id=\"input_36\" name=\"q36_liineLocation\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_36\" aria-describedby=\"input_36-description\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_dropdown\" id=\"id_13\"><label class=\"form-label form-label-top\" id=\"label_13\" for=\"input_13\" aria-hidden=\"false\"> Have You Scheduled An Appointment With Us Before? * <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <select class=\"form-dropdown\" id=\"input_13\" name=\"q13_haveYou\" style=\"width:310px\" data-component=\"dropdown\" aria-label=\"Have You Scheduled An Appointment With Us Before? *\">\n            <option value=\"\">Please Select<\/option>\n            <option data-calcvalue=\"false\" value=\"Yes - I am an existing patient\">Yes &#8211; I am an existing patient<\/option>\n            <option data-calcvalue=\"true\" value=\"No - I am a new patient\">No &#8211; I am a new patient<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_textbox\" id=\"id_14\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_14\" for=\"input_14\" aria-hidden=\"false\"> LIINE IS NEW <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <input type=\"text\" id=\"input_14\" name=\"q14_isNewText\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_14\" aria-describedby=\"input_14-description\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_dropdown\" id=\"id_34\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_34\" for=\"input_34\" aria-hidden=\"false\"> Preferred Language * <\/label>\n        <div id=\"cid_34\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <select class=\"form-dropdown\" id=\"input_34\" name=\"q34_preferredLanguage\" style=\"width:310px\" data-component=\"dropdown\" aria-label=\"Preferred Language *\">\n            <option value=\"\">Please Select<\/option>\n            <option value=\"English\" selected=\"\">English<\/option>\n            <option value=\"Spanish\">Spanish<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_textbox\" id=\"id_33\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_33\" for=\"input_33\" aria-hidden=\"false\"> LIINE REDIRECT <\/label>\n        <div id=\"cid_33\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <input type=\"text\" id=\"input_33\" name=\"q33_liineRedirect\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_33\" aria-describedby=\"input_33-description\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_37\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_37\" for=\"input_37\" aria-hidden=\"false\"> Message <\/label>\n        <div id=\"cid_37\" class=\"form-input-wide\" data-layout=\"full\"> <textarea id=\"input_37\" class=\"form-textarea\" name=\"q37_message\" style=\"width:648px;height:163px\" data-component=\"textarea\" aria-labelledby=\"label_37\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_39\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_39\" for=\"input_39_0\" aria-hidden=\"true\"> <span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_39\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_39\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_39_0\" name=\"q39_typeA39[]\" required=\"\" value=\"&lt;p&gt;&lt;span style=&quot;color: #666666; font-size: 8pt;&quot;&gt;By submitting this form and signing up for texts, you consent to receive text messages related to scheduling your appointment and related promotional offers from Empire Vein at the number provided, and agree that any associated call(s) may be recorded for quality and training purposes. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. The practice will use your personal information in accordance with its privacy policy which can be found here: &lt;a href=&quot;https:\/\/healthyveins.empirevein.com\/privacy-policy\/&quot; target=&quot;_blank&quot; rel=&quot;nofollow&quot;&gt;Click for Privacy Policy&lt;\/a&gt;.&lt;\/span&gt;&lt;\/p&gt;\"><label id=\"label_input_39_0\" for=\"input_39_0\">\n                <p><span style=\"color: #666666; font-size: 8pt;\">By submitting this form and signing up for texts, you consent to receive text messages related to scheduling your appointment and related promotional offers from Empire Vein at the number provided, and agree that any associated call(s) may be recorded for quality and training purposes. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help. The practice will use your personal information in accordance with its privacy policy which can be found here: <a href=\"https:\/\/healthyveins.empirevein.com\/privacy-policy\/\" target=\"_blank\" rel=\"nofollow\">Click for Privacy Policy<\/a>.<\/span><\/p>\n              <\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_textbox\" id=\"id_40\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_40\" for=\"input_40\" aria-hidden=\"false\"> Phone Condition <\/label>\n        <div id=\"cid_40\" class=\"form-input-wide always-hidden\" data-layout=\"half\"> <input type=\"text\" id=\"input_40\" name=\"q40_phoneCondition\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" data-component=\"textbox\" aria-labelledby=\"label_40\" aria-describedby=\"input_40-description\" value=\"\"> <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden form-field-hidden\" style=\"display:none;\" data-type=\"control_text\" id=\"id_41\">\n        <div id=\"cid_41\" class=\"form-input-wide always-hidden\" data-layout=\"full\">\n          <div id=\"text_41\" class=\"form-html\" data-component=\"text\" tabindex=\"-1\">\n            <p><span style=\"color: #bb271a; font-size: 12pt;\"><strong>Oops! It looks like the phone number you input is invalid. Please input a valid phone number in order to submit.<\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-field-hidden\" style=\"display:none;\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\" data-layout=\"full\">\n          <div data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\"><button id=\"input_2\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField legacy-submit\" data-component=\"button\" data-content=\"\">Book a Free Vein Screening<\/button><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_widget\" id=\"id_29\">\n        <div id=\"cid_29\" class=\"form-input always-hidden\" data-layout=\"full\">\n          <div style=\"width:100%;text-align:Left\" data-component=\"widget-directEmbed\">\n            <div class=\"direct-embed-widgets get-form-page-url-widget \" data-type=\"direct-embed\" style=\"width:1px;min-height:50px\"><input type=\"hidden\" id=\"input_29\" name=\"q29_typeA\" class=\"form-hidden getParentURL\">\n              <script type=\"text\/javascript\" src=\"\/\/widgets.jotform.io\/getParentUrl\/min\/scripts.min.js\"><\/script>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">Should be Empty: <input type=\"text\" name=\"website\" value=\"\"><\/li>\n    <\/ul>\n  <\/div>\n  <script>\n    JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <script>\n    JotForm.poweredByText = \"Powered by Jotform\";\n  <\/script>\n  <script>\n    JotForm.hipaa = true;\n  <\/script><input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"242175241542955\">\n  <script type=\"text\/javascript\">\n    var all_spc = document.querySelectorAll(\"form[id='242175241542955'] .si\" + \"mple\" + \"_spc\");\n    for (var i = 0; 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