<section> <fieldset id="registration_fields" class="account_creation form-group" style="border: none;"> <div class="clearfix"></div> <div class="d-flex rf_input_wrapper check-values-5 rf_only_f_0 required form-group text form-group row" data-id="5" data-f="0" data-v="0" > <label class="rf_input_label required col-3 col-sm-2 text-right form-control-label"> <span style="color: #FF5555!important">*</span> Êtes-vous</label> <div class="col-md-6"> <select class="select form-control is_required " name="fields[5]" data-type="select" data-field="5"> <option value="">Sélectionner une option</option> <option value="119" >Particulier </option> <option value="120" >Professionnel </option> <option value="121" selected="selected">Kinésithérapeute/Ostéopathe </option> <option value="122" >Ergothérapeute </option> <option value="123" >Médecin </option> <option value="124" >Maison médicale, repos, soins </option> <option value="125" >Infirmier </option> <option value="126" >Podologue </option> <option value="127" >Esthétique médecin </option> <option value="128" >Esthétique esthéticienne </option> <option value="129" >Préparateur, entraineur, coach, masseur sportif </option> <option value="130" >Club sportif, fédération </option> <option value="131" >Magasin, bandagiste, pharmacie </option> <option value="132" >Autre </option> </select> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class=" rf_input_wrapper check-values-6 rf_only_f_5 required form-group text form-group row rf_no_display rf_no_display_5_132 " data-id="6" data-f="5" data-v="132" style="display: flex" > <label class="rf_input_label required col-3 col-sm-2 text-right form-control-label"> <span style="color: #FF5555!important">*</span> Précisez ?</label> <div class="col-md-6"> <textarea name="fields[6]" class="form-control is_required" data-type="textarea" ></textarea> </div> <div class="clearfix"></div> </div> <div class="clearfix"></div> <div class="d-flex rf_input_wrapper check-values-4 rf_only_f_0 required form-group text form-group row" data-id="4" data-f="0" data-v="0" > <label class="rf_input_label col-3 col-sm-2 text-right form-control-label"> Numéro INAMI </label> <div class="col-md-6"> <textarea name="fields[4]" class="form-control " data-type="textarea" >5-45013-30-527</textarea> </div> <div class="clearfix"></div> </div> </fieldset> <div class="form-group row "> <label class="col-md-3 form-control-label required"></label> <div class="col-md-6"> </div> </div> <style> .rf_no_display { display: none;} #registration_fields .radio-inline, #registration_fields .checkbox { display: inline-block; margin-right: 3%} #registration_fields .radio-inline .radio, #registration_fields .checkbox .checker { display:inline-block; padding-right: 3px; vertical-align: middle} </style> </section> <div class="form-group row " style="display: none;"> <label class="col-md-3 form-control-label "> Select Group </label> <div class="col-md-6"> <select id="customer_groups" onchange="checkval(this.value)" class="form-control" name="customer_groups" autocomplete="off" > <option value="">Select Group</option> <option value="4">Professionnel</option> </select> <p id="auto-find" class="alert alert-warning" style="display: none">users are required to be manually approved.</p> </div> </div> <div class="form-group row " style="display: none;"> <label class="col-md-3 form-control-label required"> Request Message </label> <div class="col-md-6"> <textarea id="request_message" class="form-control" name="request_message" autocomplete="off" ></textarea> </div> </div> <script type="text/javascript"> var autogroups = "4,8,9,10"; function checkval(val){ var autogroupsarray = autogroups.split(","); var end = val; if (autogroupsarray.includes(end) || end=='') { document.getElementById("auto-find").style.display='none'; } else if (autogroupsarray == end) { document.getElementById("auto-find").style.display='none'; } else { document.getElementById("auto-find").style.display='block'; } } </script>