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PHP Form Quick Fixes Needed ASAP

I need a few quick fixes on the following form:

[url removed, login to view]

PRIORITY #1. Last question in "health information" section. When you check "yes" a text box appears. When you write information in the box, which you are supposed to do, a validation error keeps the form from being submitted. (you are welcome to try the form).

The html code, plus the javascript validation utility are attached (along with the js form "health-form" which the form calls up when online. This probably a very easy fix for someone who knows what they're doing (LoL, not me).

Priority #2. Under "health information" when you check "yes" to "are you currently insured" I would like to add a couple of new options that also appear in addition to the drop down box with company names. These would be text box or drop down menu. No more than 3 -- they need to all appear at the same time along with the first drop down box. Validation is really not necessary for these, but if it is easy to do, then we can add validation.

Priority #3. There are 2 things I would like to add in the last section "contact information." First, I would like to add an email verification that makes the user enter the email twice and they must match up to validate. Also, I would like to add a few telephone numbers that would invalidate the phone number entry. For example, if someone enters 800-555-1212, that is obviously a fake number, so I would like to have "555" as an invalid notice if it is entered in the telephone prefix area. Likewise, if people enter "0000" as their last four digits, this should invalidate.

Issue #4. There is a strange little white space area to the very bottom left hand corner of the form.

Again, these should be easy for someone who knows what he (or she) is doing.

If you have any questions about this small project, please PM.

Please provide some kind of evidence that you know what you're doing with these forms, such as a link to similar forms you have made. (The tricky thing with this form is the "hidden fields" that make the form look much smaller than it really is when people start the form)

If you have alternative ideas you would like to propose, please include info in PM. For example, if you want to re-do the entire form from scratch using AJAX, for example, then please specify.

No auto-replies, please. If you are serious about bidding, please include this keyword: FORM202

Thank you!

Kemahiran: AJAX, Javascript, PHP, Memasang Skrip

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Tentang Majikan:
( 5 ulasan ) Las Vegas, United States

ID Projek: #347647