<!--Begin CTCT Sign-Up Form--> <!-- EFD 1.0.0 [Wed Sep 21 10:51:29 EDT 2016] --> <link rel='stylesheet' type='text/css' href='https://static.ctctcdn.com/h/contacts-embedded-signup-assets/1.0.2/css/signup-form.css'> <div class="ctct-embed-signup" style="font: 16px Helvetica Neue, Arial, sans-serif; font: 1rem Helvetica Neue, Arial, sans-serif; line-height: 1.5; -webkit-font-smoothing: antialiased;"> <div style="color:#93397F; background-color:#FFFFFF; border-radius:5px;"> <span id="success_message" style="display:none;"> <div style="text-align:center;">Thanks for signing up!</div> </span> <form data-id="embedded_signup:form" class="ctct-custom-form Form" name="embedded_signup" method="POST" action="https://visitor2.constantcontact.com/api/signup"> <h2 style="margin:0;">Join Email List</h2> <p>Thank you for your interest in WorldCare International, Inc., the gold standard in medical second opinions! Join our email list for our latest news and updates!</p> <!-- The following code must be included to ensure your sign-up form works properly. --> <input data-id="ca:input" type="hidden" name="ca" value="e6ac934c-b3f5-42c0-9f98-ec84e4930efd"> <input data-id="list:input" type="hidden" name="list" value="1072061486"> <input data-id="source:input" type="hidden" name="source" value="EFD"> <input data-id="required:input" type="hidden" name="required" value="list,email,first_name,last_name,company"> <input data-id="url:input" type="hidden" name="url" value=""> <p data-id="Email Address:p" ><label data-id="Email Address:label" data-name="email" class="ctct-form-required">Email Address</label> <input data-id="Email Address:input" type="text" name="email" value="" maxlength="80"></p> <p data-id="First Name:p" ><label data-id="First Name:label" data-name="first_name" class="ctct-form-required">First Name</label> <input data-id="First Name:input" type="text" name="first_name" value="" maxlength="50"></p> <p data-id="Last Name:p" ><label data-id="Last Name:label" data-name="last_name" class="ctct-form-required">Last Name</label> <input data-id="Last Name:input" type="text" name="last_name" value="" maxlength="50"></p> <p data-id="Company:p" ><label data-id="Company:label" data-name="company" class="ctct-form-required">Company</label> <input data-id="Company:input" type="text" name="company" value="" maxlength="50"></p> <button type="submit" class="Button ctct-button Button--block Button-secondary" data-enabled="enabled">Sign Up</button> <div><p class="ctct-form-footer">By submitting this form you are granting WorldCare permission to email you. You may unsubscribe via the link found at the bottom of every email. (See our <a href="http://www.constantcontact.com/legal/privacy-statement" target="_blank">Email Privacy Policy</a> for details.) Emails are serviced by Constant Contact.</p></div> </form> </div> </div> <script type='text/javascript'> var localizedErrMap = {}; localizedErrMap['required'] = 'This field is required.'; localizedErrMap['ca'] = 'An unexpected error occurred while attempting to send email.'; localizedErrMap['email'] = 'Please enter your email address in name@email.com format.'; localizedErrMap['birthday'] = 'Please enter birthday in MM/DD format.'; localizedErrMap['anniversary'] = 'Please enter anniversary in MM/DD/YYYY format.'; localizedErrMap['custom_date'] = 'Please enter this date in MM/DD/YYYY format.'; localizedErrMap['list'] = 'Please select at least one email list.'; localizedErrMap['generic'] = 'This field is invalid.'; localizedErrMap['shared'] = 'Sorry, we could not complete your sign-up. Please contact us to resolve this.'; localizedErrMap['state_mismatch'] = 'Mismatched State/Province and Country.'; localizedErrMap['state_province'] = 'Select a state/province'; localizedErrMap['selectcountry'] = 'Select a country'; var postURL = 'https://visitor2.constantcontact.com/api/signup'; </script> <script type='text/javascript' src='https://static.ctctcdn.com/h/contacts-embedded-signup-assets/1.0.2/js/signup-form.js'></script> <!--End CTCT Sign-Up Form-->