{"type":"form","data":{"fields":[{"id":"name-1","element_id":"name-1","form_id":"wrapper-8770-8993","parent_group":"","type":"name","options":[],"cols":"6","conditions":[],"wrapper_id":"wrapper-8770-8993","field_label":"Name","placeholder":"","prefix_label":"Prefix","fname_label":"First Name","fname_placeholder":"E.g. John","mname_label":"Middle Name","mname_placeholder":"E.g. Smith","lname_label":"Last Name","lname_placeholder":"E.g. 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Example: a $10,000 payment results in total fees to me of <b>$10,290.30<\/b> (invoice amount times 2.9%, plus $0.30). However, the processing fee for that NEW total must be taken into account, so the total payment will be slightly higher; in this example, <b>$10,298.72<\/b> ($10,290.30 times 2.9%, plus $0.30).","condition_rule":"any"},{"id":"text-3","element_id":"text-3","form_id":"wrapper-7515-3120","parent_group":"","type":"text","options":[],"cols":"12","conditions":[{"element_id":"select-1","rule":"is","value":"Other"}],"wrapper_id":"wrapper-7515-3120","input_type":"line","limit_type":"characters","field_label":"Reason for Payment","placeholder":"","formid":"wrapper-7515-3120","required":"1","required_message":"You indicated \"Other\" above. 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Copy and save the link or enter your email address below to have the link sent to your mail.<\/p><p>These fields weren't saved to your submission draft: Paypal, Stripe, Signature, Password, Captcha, and Upload. Kindly fill them out before submitting the form.<\/p>","notification_count":2,"button-submit-color-static":"#0c1b31","cform-asterisk-color":"#ffa727","input-bg":"#ffffff","dropdown-background":"#ededed","dropdown-border":"#0c1b31","select-background-static":"#ffffff","form-substyle":"default"},"client_id":"","integration_conditions":[],"behaviors":[{"slug":"behavior-5741","autoclose":"1","autoclose-time":"5","newtab":"sametab","submission-behaviour":"behaviour-redirect","thankyou-message":"Thank you for contacting us, we will be in touch shortly.","redirect-url":"\/payment-confirmation\/","conditions":[]}],"notifications":[{"slug":"notification-1234-4567","label":"Admin Notification","email-recipients":"default","recipients":"fneglia@nucmedimaging.com,gil@altimac.com","email-subject":"Online payment made by {text-1} at {submission_time}","email-editor":"<p>Online invoice payment received from {text-1} at {submission_time}:<\/p>\n<p>{all_fields}<\/p>\n<p>---<br>Sent from {site_url}.<\/p>","email-attachment":"true","conditions":[],"routing":[],"from-name":"NMIC Website Submission Agent","form-email":"website@nucmedimaging.com","replyto-email":"{email-1}","cc-email":"","bcc-email":""},{"slug":"notification-4306-9264","email-subject":"Payment Confirmation from NMIC","label":"Payer Notification","email-editor":"<p>Hi, {name-1} and thank you for your payment of $<strong>{currency-1}<\/strong>.<\/p>\n<p>You should also receive an email confirmation from Stripe, our payment processor, for this transaction.<\/p>\n<p>--<span class=\"Apple-converted-space\">&nbsp;<\/span><\/p>\n<div class=\"\" id=\"sig\">Frank Neglia<\/div>\n<div class=\"\" id=\"sig\"><strong>Nuclear Medicine Imaging Consultants LLC<\/strong><br>95 West Main St.&nbsp;Suite 5 \u2013 301<br>Chester, NJ 07930<\/div>\n<div class=\"\" id=\"sig\">(973) 668-9251<\/div>","recipients":"{email-1}","from-name":"Nuclear Medicine Imaging Consultants LLC","form-email":"website@nucmedimaging.com","replyto-email":"fneglia@nucmedimaging.com","cc-email":"","bcc-email":"","email-recipients":"default","routing":[],"conditions":[]}]},"status":"publish","version":"1.48.2"}