jQuery1124024067209496251563_1628707024129({"Id":2360,"Vid":2360,"Status":"approved","Name":"Web Content.2. Contact Us - Teladoc Health","Description":"","Layout":"left","GutterWidth":5,"OffsetWidth":5,"HasTwoButtons":true,"SubmitLabel":"Submit","ResetLabel":"Clear","ButtonLocation":"110","LabelWidth":100,"FieldWidth":150,"ToolTipType":"none","FontFamily":"inherit","FontSize":"13px","FontColor":"#333","FontUrl":null,"LineMargin":5,"ProcessorVersion":2,"CreatedByUserid":408,"ProcessOptions":{"language":"English","locale":"en_US","profiling":{"isEnabled":true,"numberOfProfilingFields":3,"alwaysShowFields":[]},"socialSignOn":{"isEnabled":false,"enabledNetworks":[],"cfId":null,"codeSnippet":null},"knownLead":{"type":"form","template":""}},"EnableDeferredMode":0,"EnableCaptcha":0,"EnableGlobalFormValidationRule":1,"ButtonType":null,"ButtonImageUrl":null,"ButtonText":null,"ButtonSubmissionText":"Please Wait","ButtonStyle":{"id":14,"className":"mktoNative","css":"","buttonColor":null},"ThemeStyle":{"id":3,"displayOrder":7,"name":"Plain","backgroundColor":"#FFF","layout":"left","fontFamily":"inherit","fontSize":"13px","fontColor":"#333","offsetWidth":5,"gutterWidth":5,"labelWidth":100,"fieldWidth":150,"lineMargin":5,"useBackgroundColorOnPreview":false,"css":".mktoForm fieldset.mkt3-formEditorFieldContainer{border: solid 1px gray;}.mktoForm fieldset.mkt3-formEditorFieldContainer legend{padding:0 1em;}","href":"css\/forms2-theme-plain.css","buttonStyleId":14},"ThemeStyleOverride":"\/* Add your custom CSS below *\/\n.mktoHtmlText {\n\tline-height: 1;\n \tmargin-bottom: 1rem;\n}","LiveStreamSettings":null,"rows":[[{"Id":61177,"Name":"Email","IsRequired":true,"Datatype":"email","Maxlength":255,"InputLabel":"Work Email:","InputInitialValue":"","InputSourceChannel":"constant","FieldWidth":300,"LabelWidth":150,"PlaceholderText":"Email Address","ValidationMessage":"Must be valid email. \u003Cspan class='mktoErrorDetail'\u003Eexample@yourdomain.com\u003C\/span\u003E","DisablePrefill":true}],[{"Id":61178,"Name":"FirstName","IsRequired":true,"Datatype":"string","Maxlength":255,"InputLabel":"First Name:","InputInitialValue":"","InputSourceChannel":"constant","FieldWidth":300,"LabelWidth":150,"PlaceholderText":"First Name","ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61179,"Name":"LastName","IsRequired":true,"Datatype":"string","Maxlength":255,"InputLabel":"Last Name:","InputInitialValue":"","InputSourceChannel":"constant","FieldWidth":300,"LabelWidth":150,"PlaceholderText":"Last Name","ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61181,"Name":"Phone","IsRequired":true,"Datatype":"phone","Maxlength":255,"InputLabel":"Phone Number:","InputInitialValue":"","InputSourceChannel":"constant","FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"Phone Number","ValidationMessage":"Must be a phone number. \u003Cspan class='mktoErrorDetail'\u003E503-555-1212\u003C\/span\u003E","DisablePrefill":true}],[{"Id":61180,"Name":"Title","IsRequired":true,"Datatype":"string","Maxlength":255,"InputLabel":"Job Title:","InputInitialValue":"","InputSourceChannel":"constant","FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"Title","ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61182,"Name":"Company","IsRequired":true,"Datatype":"string","Maxlength":255,"InputLabel":"Company\/Organization:","InputInitialValue":"","InputSourceChannel":"constant","FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"Company","ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61190,"Name":"Account_Type__c_lead","IsRequired":true,"Datatype":"picklist","Maxlength":255,"PicklistValues":[{"label":"Select Organization Type:","value":"","selected":true,"isDefault":true},{"label":"Broker","value":"Broker"},{"label":"Consultant","value":"Consultant"},{"label":"Employer","value":"Employer"},{"label":"Health Plan","value":"Health Plan"},{"label":"Hospital and Health System","value":"Hospital and Health System"},{"label":"Insurance","value":"Insurance"},{"label":"Labor","value":"Labor"},{"label":"Physician \/ Hospital","value":"Physician \/ Hospital"},{"label":"Referral Agent","value":"Referral Agent"},{"label":"Reseller","value":"Reseller"},{"label":"TPA","value":"TPA"},{"label":"Vendor","value":"Vendor"}],"DefaultValue":[""],"InputLabel":"Organization Type:","InputInitialValue":"","InputSourceChannel":"constant","VisibleRows":4,"FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61198,"Name":"NumberOfEmployees","IsRequired":true,"Datatype":"number","InputLabel":"Organization Size:","InputInitialValue":"","InputSourceChannel":"constant","MinimumNumber":1,"FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"Total # of Employees","ValidationMessage":"Must be a number."}],[{"Id":61188,"Name":"Country","IsRequired":true,"Datatype":"picklist","Maxlength":255,"PicklistValues":[{"label":"Select your country","value":"","selected":true,"isDefault":true},{"label":"United States","value":"United States"},{"label":"Canada","value":"Canada"},{"label":"Afghanistan","value":"Afghanistan"},{"label":"Aland Islands","value":"Aland Islands"},{"label":"Albania","value":"Albania"},{"label":"Algeria","value":"Algeria"},{"label":"Andorra","value":"Andorra"},{"label":"Angola","value":"Angola"},{"label":"Anguilla","value":"Anguilla"},{"label":"Antarctica","value":"Antarctica"},{"label":"Antigua and Barbuda","value":"Antigua and Barbuda"},{"label":"Argentina","value":"Argentina"},{"label":"Armenia","value":"Armenia"},{"label":"Aruba","value":"Aruba"},{"label":"Australia","value":"Australia"},{"label":"Austria","value":"Austria"},{"label":"Azerbaijan","value":"Azerbaijan"},{"label":"Bahamas","value":"Bahamas"},{"label":"Bahrain","value":"Bahrain"},{"label":"Bangladesh","value":"Bangladesh"},{"label":"Barbados","value":"Barbados"},{"label":"Belarus","value":"Belarus"},{"label":"Belgium","value":"Belgium"},{"label":"Belize","value":"Belize"},{"label":"Benin","value":"Benin"},{"label":"Bermuda","value":"Bermuda"},{"label":"Bhutan","value":"Bhutan"},{"label":"Bolivia, Plurinational State of","value":"Bolivia, Plurinational State of"},{"label":"Bonaire, Sint Eustatius and Saba","value":"Bonaire, Sint Eustatius and Saba"},{"label":"Bosnia and Herzegovina","value":"Bosnia and Herzegovina"},{"label":"Botswana","value":"Botswana"},{"label":"Bouvet Island","value":"Bouvet Island"},{"label":"Brazil","value":"Brazil"},{"label":"British Indian Ocean Territory","value":"British Indian Ocean Territory"},{"label":"Brunei Darussalam","value":"Brunei Darussalam"},{"label":"Bulgaria","value":"Bulgaria"},{"label":"Burkina Faso","value":"Burkina Faso"},{"label":"Burundi","value":"Burundi"},{"label":"Cambodia","value":"Cambodia"},{"label":"Cameroon","value":"Cameroon"},{"label":"Cape Verde","value":"Cape Verde"},{"label":"Cayman Islands","value":"Cayman Islands"},{"label":"Central African Republic","value":"Central African Republic"},{"label":"Chad","value":"Chad"},{"label":"Chile","value":"Chile"},{"label":"China","value":"China"},{"label":"Christmas Island","value":"Christmas Island"},{"label":"Cocos (Keeling) Islands","value":"Cocos (Keeling) Islands"},{"label":"Colombia","value":"Colombia"},{"label":"Comoros","value":"Comoros"},{"label":"Congo","value":"Congo"},{"label":"Congo, the Democratic Republic of the","value":"Congo, the Democratic Republic of the"},{"label":"Cook Islands","value":"Cook Islands"},{"label":"Costa Rica","value":"Costa Rica"},{"label":"Cote d\u2019Ivoire","value":"Cote d\u2019Ivoire"},{"label":"Croatia","value":"Croatia"},{"label":"Cuba","value":"Cuba"},{"label":"Cura\u00e7ao","value":"Cura\u00e7ao"},{"label":"Cyprus","value":"Cyprus"},{"label":"Czech Republic","value":"Czech Republic"},{"label":"Denmark","value":"Denmark"},{"label":"Djibouti","value":"Djibouti"},{"label":"Dominica","value":"Dominica"},{"label":"Dominican Republic","value":"Dominican Republic"},{"label":"Ecuador","value":"Ecuador"},{"label":"Egypt","value":"Egypt"},{"label":"El Salvador","value":"El Salvador"},{"label":"Equatorial Guinea","value":"Equatorial Guinea"},{"label":"Eritrea","value":"Eritrea"},{"label":"Estonia","value":"Estonia"},{"label":"Ethiopia","value":"Ethiopia"},{"label":"Falkland Islands (Malvinas)","value":"Falkland Islands (Malvinas)"},{"label":"Faroe Islands","value":"Faroe Islands"},{"label":"Fiji","value":"Fiji"},{"label":"Finland","value":"Finland"},{"label":"France","value":"France"},{"label":"French Guiana","value":"French Guiana"},{"label":"French Polynesia","value":"French Polynesia"},{"label":"French Southern Territories","value":"French Southern Territories"},{"label":"Gabon","value":"Gabon"},{"label":"Gambia","value":"Gambia"},{"label":"Georgia","value":"Georgia"},{"label":"Germany","value":"Germany"},{"label":"Ghana","value":"Ghana"},{"label":"Gibraltar","value":"Gibraltar"},{"label":"Greece","value":"Greece"},{"label":"Greenland","value":"Greenland"},{"label":"Grenada","value":"Grenada"},{"label":"Guadeloupe","value":"Guadeloupe"},{"label":"Guatemala","value":"Guatemala"},{"label":"Guernsey","value":"Guernsey"},{"label":"Guinea","value":"Guinea"},{"label":"Guinea-Bissau","value":"Guinea-Bissau"},{"label":"Guyana","value":"Guyana"},{"label":"Haiti","value":"Haiti"},{"label":"Heard Island and McDonald Islands","value":"Heard Island and McDonald Islands"},{"label":"Holy See (Vatican City State)","value":"Holy See (Vatican City State)"},{"label":"Honduras","value":"Honduras"},{"label":"Hong Kong","value":"Hong Kong"},{"label":"Hungary","value":"Hungary"},{"label":"Iceland","value":"Iceland"},{"label":"India","value":"India"},{"label":"Indonesia","value":"Indonesia"},{"label":"Iran, Islamic Republic of","value":"Iran, Islamic Republic of"},{"label":"Iraq","value":"Iraq"},{"label":"Ireland","value":"Ireland"},{"label":"Isle of Man","value":"Isle of Man"},{"label":"Israel","value":"Israel"},{"label":"Italy","value":"Italy"},{"label":"Jamaica","value":"Jamaica"},{"label":"Japan","value":"Japan"},{"label":"Jersey","value":"Jersey"},{"label":"Jordan","value":"Jordan"},{"label":"Kazakhstan","value":"Kazakhstan"},{"label":"Kenya","value":"Kenya"},{"label":"Kiribati","value":"Kiribati"},{"label":"Korea, Democratic People\u2019s Republic of","value":"Korea, Democratic People\u2019s Republic of"},{"label":"Korea, Republic of","value":"Korea, Republic of"},{"label":"Kuwait","value":"Kuwait"},{"label":"Kyrgyzstan","value":"Kyrgyzstan"},{"label":"Lao People\u2019s Democratic Republic","value":"Lao People\u2019s Democratic Republic"},{"label":"Latvia","value":"Latvia"},{"label":"Lebanon","value":"Lebanon"},{"label":"Lesotho","value":"Lesotho"},{"label":"Liberia","value":"Liberia"},{"label":"Libya","value":"Libya"},{"label":"Liechtenstein","value":"Liechtenstein"},{"label":"Lithuania","value":"Lithuania"},{"label":"Luxembourg","value":"Luxembourg"},{"label":"Macao","value":"Macao"},{"label":"Macedonia, the former Yugoslav Republic of","value":"Macedonia, the former Yugoslav Republic of"},{"label":"Madagascar","value":"Madagascar"},{"label":"Malawi","value":"Malawi"},{"label":"Malaysia","value":"Malaysia"},{"label":"Maldives","value":"Maldives"},{"label":"Mali","value":"Mali"},{"label":"Malta","value":"Malta"},{"label":"Martinique","value":"Martinique"},{"label":"Mauritania","value":"Mauritania"},{"label":"Mauritius","value":"Mauritius"},{"label":"Mayotte","value":"Mayotte"},{"label":"Mexico","value":"Mexico"},{"label":"Moldova, Republic of","value":"Moldova, Republic of"},{"label":"Monaco","value":"Monaco"},{"label":"Mongolia","value":"Mongolia"},{"label":"Montenegro","value":"Montenegro"},{"label":"Montserrat","value":"Montserrat"},{"label":"Morocco","value":"Morocco"},{"label":"Mozambique","value":"Mozambique"},{"label":"Myanmar","value":"Myanmar"},{"label":"Namibia","value":"Namibia"},{"label":"Nauru","value":"Nauru"},{"label":"Nepal","value":"Nepal"},{"label":"Netherlands","value":"Netherlands"},{"label":"New Caledonia","value":"New Caledonia"},{"label":"New Zealand","value":"New Zealand"},{"label":"Nicaragua","value":"Nicaragua"},{"label":"Niger","value":"Niger"},{"label":"Nigeria","value":"Nigeria"},{"label":"Niue","value":"Niue"},{"label":"Norfolk Island","value":"Norfolk Island"},{"label":"Norway","value":"Norway"},{"label":"Oman","value":"Oman"},{"label":"Pakistan","value":"Pakistan"},{"label":"Palestine","value":"Palestine"},{"label":"Panama","value":"Panama"},{"label":"Papua New Guinea","value":"Papua New Guinea"},{"label":"Paraguay","value":"Paraguay"},{"label":"Peru","value":"Peru"},{"label":"Philippines","value":"Philippines"},{"label":"Pitcairn","value":"Pitcairn"},{"label":"Poland","value":"Poland"},{"label":"Portugal","value":"Portugal"},{"label":"Qatar","value":"Qatar"},{"label":"Reunion","value":"Reunion"},{"label":"Romania","value":"Romania"},{"label":"Russian Federation","value":"Russian Federation"},{"label":"Rwanda","value":"Rwanda"},{"label":"Saint Barth\u00e9lemy","value":"Saint Barth\u00e9lemy"},{"label":"Saint Helena, Ascension and Tristan da Cunha","value":"Saint Helena, Ascension and Tristan da Cunha"},{"label":"Saint Kitts and Nevis","value":"Saint Kitts and Nevis"},{"label":"Saint Lucia","value":"Saint Lucia"},{"label":"Saint Martin (French part)","value":"Saint Martin (French part)"},{"label":"Saint Pierre and Miquelon","value":"Saint Pierre and Miquelon"},{"label":"Saint Vincent and the Grenadines","value":"Saint Vincent and the Grenadines"},{"label":"Samoa","value":"Samoa"},{"label":"San Marino","value":"San Marino"},{"label":"Sao Tome and Principe","value":"Sao Tome and Principe"},{"label":"Saudi Arabia","value":"Saudi Arabia"},{"label":"Senegal","value":"Senegal"},{"label":"Serbia","value":"Serbia"},{"label":"Seychelles","value":"Seychelles"},{"label":"Sierra Leone","value":"Sierra Leone"},{"label":"Singapore","value":"Singapore"},{"label":"Sint Maarten (Dutch part)","value":"Sint Maarten (Dutch part)"},{"label":"Slovakia","value":"Slovakia"},{"label":"Slovenia","value":"Slovenia"},{"label":"Solomon Islands","value":"Solomon Islands"},{"label":"Somalia","value":"Somalia"},{"label":"South Africa","value":"South Africa"},{"label":"South Georgia and the South Sandwich Islands","value":"South Georgia and the South Sandwich Islands"},{"label":"South Sudan","value":"South Sudan"},{"label":"Spain","value":"Spain"},{"label":"Sri Lanka","value":"Sri Lanka"},{"label":"Sudan","value":"Sudan"},{"label":"Suriname","value":"Suriname"},{"label":"Svalbard and Jan Mayen","value":"Svalbard and Jan Mayen"},{"label":"Swaziland","value":"Swaziland"},{"label":"Sweden","value":"Sweden"},{"label":"Switzerland","value":"Switzerland"},{"label":"Syrian Arab Republic","value":"Syrian Arab Republic"},{"label":"Taiwan","value":"Taiwan"},{"label":"Tajikistan","value":"Tajikistan"},{"label":"Tanzania, United Republic of","value":"Tanzania, United Republic of"},{"label":"Thailand","value":"Thailand"},{"label":"Timor-Leste","value":"Timor-Leste"},{"label":"Togo","value":"Togo"},{"label":"Tokelau","value":"Tokelau"},{"label":"Tonga","value":"Tonga"},{"label":"Trinidad and Tobago","value":"Trinidad and Tobago"},{"label":"Tunisia","value":"Tunisia"},{"label":"Turkey","value":"Turkey"},{"label":"Turkmenistan","value":"Turkmenistan"},{"label":"Turks and Caicos Islands","value":"Turks and Caicos Islands"},{"label":"Tuvalu","value":"Tuvalu"},{"label":"Uganda","value":"Uganda"},{"label":"Ukraine","value":"Ukraine"},{"label":"United Arab Emirates","value":"United Arab Emirates"},{"label":"United Kingdom","value":"United Kingdom"},{"label":"Uruguay","value":"Uruguay"},{"label":"Uzbekistan","value":"Uzbekistan"},{"label":"Vanuatu","value":"Vanuatu"},{"label":"Venezuela, Bolivarian Republic of","value":"Venezuela, Bolivarian Republic of"},{"label":"Vietnam","value":"Vietnam"},{"label":"Virgin Islands, British","value":"Virgin Islands, British"},{"label":"Wallis and Futuna","value":"Wallis and Futuna"},{"label":"Western Sahara","value":"Western Sahara"},{"label":"Yemen","value":"Yemen"},{"label":"Zambia","value":"Zambia"},{"label":"Zimbabwe","value":"Zimbabwe"}],"DefaultValue":[""],"InputLabel":"Country:","InputInitialValue":"","InputSourceChannel":"constant","VisibleRows":4,"FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"Country","ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61183,"Name":"State","IsRequired":true,"Datatype":"picklist","Maxlength":255,"PicklistValues":[{"label":"Select your state","value":"","selected":true,"isDefault":true},{"label":"Alaska ","value":"Alaska"},{"label":"Alabama ","value":"Alabama"},{"label":"Arkansas ","value":"Arkansas"},{"label":"Arizona ","value":"Arizona"},{"label":"California ","value":"California"},{"label":"Colorado ","value":"Colorado"},{"label":"Connecticut ","value":"Connecticut"},{"label":"District of Columbia ","value":"District of Columbia"},{"label":"Delaware ","value":"Delaware"},{"label":"Florida ","value":"Florida"},{"label":"Georgia ","value":"Georgia"},{"label":"Hawaii ","value":"Hawaii"},{"label":"Iowa ","value":"Iowa"},{"label":"Idaho ","value":"Idaho"},{"label":"Illinois ","value":"Illinois"},{"label":"Indiana ","value":"Indiana"},{"label":"Kansas ","value":"Kansas"},{"label":"Kentucky ","value":"Kentucky"},{"label":"Louisiana ","value":"Louisiana"},{"label":"Massachusetts ","value":"Massachusetts"},{"label":"Maryland ","value":"Maryland"},{"label":"Maine ","value":"Maine"},{"label":"Michigan ","value":"Michigan"},{"label":"Minnesota ","value":"Minnesota"},{"label":"Missouri ","value":"Missouri"},{"label":"Mississippi ","value":"Mississippi"},{"label":"Montana ","value":"Montana"},{"label":"North Carolina ","value":"North Carolina"},{"label":"North Dakota ","value":"North Dakota"},{"label":"Nebraska ","value":"Nebraska"},{"label":"New Hampshire ","value":"New Hampshire"},{"label":"New Jersey ","value":"New Jersey"},{"label":"New Mexico ","value":"New Mexico"},{"label":"Nevada ","value":"Nevada"},{"label":"New York ","value":"New York"},{"label":"Ohio ","value":"Ohio"},{"label":"Oklahoma ","value":"Oklahoma"},{"label":"Oregon ","value":"Oregon"},{"label":"Pennsylvania ","value":"Pennsylvania"},{"label":"Puerto Rico ","value":"Puerto Rico"},{"label":"Rhode Island ","value":"Rhode Island"},{"label":"South Carolina ","value":"South Carolina"},{"label":"South Dakota ","value":"South Dakota"},{"label":"Tennessee ","value":"Tennessee"},{"label":"Texas ","value":"Texas"},{"label":"Utah ","value":"Utah"},{"label":"Virginia ","value":"Virginia"},{"label":"Vermont ","value":"Vermont"},{"label":"Washington ","value":"Washington"},{"label":"Wisconsin ","value":"Wisconsin"},{"label":"West Virginia ","value":"West Virginia"},{"label":"Wyoming ","value":"Wyoming"},{"label":"Alberta","value":"Alberta"},{"label":"British Columbia","value":"British Columbia"},{"label":"Manitoba","value":"Manitoba"},{"label":"New Brunswick","value":"New Brunswick"},{"label":"Newfoundland and Labrador","value":"Newfoundland and Labrador"},{"label":"Northwest Territories","value":"Northwest Territories"},{"label":"Nova Scotia","value":"Nova Scotia"},{"label":"Nunavut","value":"Nunavut"},{"label":"Ontario","value":"Ontario"},{"label":"Prince Edward Island","value":"Prince Edward Island"},{"label":"Quebec","value":"Quebec"},{"label":"Saskatchewan","value":"Saskatchewan"},{"label":"Yukon","value":"Yukon"}],"DefaultValue":[""],"InputLabel":"State:","InputInitialValue":"","InputSourceChannel":"constant","VisibleRows":4,"FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"State or Providence","ValidationMessage":"This field is required.","VisibilityRule":{"defaultVisibility":"hide","rules":[{"subjectField":"Country","fieldLabel":"Country","operator":"equal","values":["Canada"],"altLabel":"Province:","picklistFilterValues":[{"label":"Select Province...","value":""},{"label":"Alberta","value":"Alberta"},{"label":"British Columbia","value":"British Columbia"},{"label":"Manitoba","value":"Manitoba"},{"label":"New Brunswick","value":"New Brunswick"},{"label":"Newfoundland and Labrador","value":"Newfoundland and Labrador"},{"label":"Northwest Territories","value":"Northwest Territories"},{"label":"Nova Scotia","value":"Nova Scotia"},{"label":"Nunavut","value":"Nunavut"},{"label":"Ontario","value":"Ontario"},{"label":"Prince Edward Island","value":"Prince Edward Island"},{"label":"Quebec","value":"Quebec"},{"label":"Saskatchewan","value":"Saskatchewan"},{"label":"Yukon","value":"Yukon"}]},{"subjectField":"Country","fieldLabel":"Country","operator":"equal","values":["United States"],"altLabel":"State:","picklistFilterValues":[{"label":"Select your state","value":""},{"label":"Alaska ","value":"Alaska"},{"label":"Alabama ","value":"Alabama"},{"label":"Arkansas ","value":"Arkansas"},{"label":"American Samoa ","value":"American Samoa"},{"label":"Arizona ","value":"Arizona"},{"label":"California ","value":"California"},{"label":"Colorado ","value":"Colorado"},{"label":"Connecticut ","value":"Connecticut"},{"label":"District of Columbia ","value":"District of Columbia"},{"label":"Delaware ","value":"Delaware"},{"label":"Florida ","value":"Florida"},{"label":"Georgia ","value":"Georgia"},{"label":"Guam ","value":"Guam"},{"label":"Hawaii ","value":"Hawaii"},{"label":"Iowa ","value":"Iowa"},{"label":"Idaho ","value":"Idaho"},{"label":"Illinois ","value":"Illinois"},{"label":"Indiana ","value":"Indiana"},{"label":"Kansas ","value":"Kansas"},{"label":"Kentucky ","value":"Kentucky"},{"label":"Louisiana ","value":"Louisiana"},{"label":"Massachusetts ","value":"Massachusetts"},{"label":"Maryland ","value":"Maryland"},{"label":"Maine ","value":"Maine"},{"label":"Michigan ","value":"Michigan"},{"label":"Minnesota ","value":"Minnesota"},{"label":"Missouri ","value":"Missouri"},{"label":"Mississippi ","value":"Mississippi"},{"label":"Montana ","value":"Montana"},{"label":"North Carolina ","value":"North Carolina"},{"label":"North Dakota ","value":"North Dakota"},{"label":"Nebraska ","value":"Nebraska"},{"label":"New Hampshire ","value":"New Hampshire"},{"label":"New Jersey ","value":"New Jersey"},{"label":"New Mexico ","value":"New Mexico"},{"label":"Nevada ","value":"Nevada"},{"label":"New York ","value":"New York"},{"label":"Ohio ","value":"Ohio"},{"label":"Oklahoma ","value":"Oklahoma"},{"label":"Oregon ","value":"Oregon"},{"label":"Pennsylvania ","value":"Pennsylvania"},{"label":"Puerto Rico ","value":"Puerto Rico"},{"label":"Rhode Island ","value":"Rhode Island"},{"label":"South Carolina ","value":"South Carolina"},{"label":"South Dakota ","value":"South Dakota"},{"label":"Tennessee ","value":"Tennessee"},{"label":"Texas ","value":"Texas"},{"label":"Utah ","value":"Utah"},{"label":"Virginia ","value":"Virginia"},{"label":"Virgin Islands ","value":"Virgin Islands"},{"label":"Vermont ","value":"Vermont"},{"label":"Washington ","value":"Washington"},{"label":"Wisconsin ","value":"Wisconsin"},{"label":"West Virginia ","value":"West Virginia"},{"label":"Wyoming ","value":"Wyoming"}]}]},"DisablePrefill":true}],[{"Id":61197,"Name":"commentsMostRecent","IsRequired":true,"Datatype":"textarea","Maxlength":2000,"InputLabel":"Comments:","InputInitialValue":"","InputSourceChannel":"constant","VisibleRows":4,"FieldWidth":300,"LabelWidth":150,"ProfilingFieldNumber":0,"PlaceholderText":"Please specify the reason for your inquiry with details: General information, pricing, request for proposal (RFP), request for information (RFI).","ValidationMessage":"This field is required.","DisablePrefill":true}],[{"Id":61191,"Name":"HtmlText_2019-04-08T16:15:42.941Z","Datatype":"htmltext","InputInitialValue":"","LabelWidth":260,"ProfilingFieldNumber":0,"Htmltext":"\u003Csmall style=\"line-height: 1 !important; margin-bottom: 1rem;\"\u003EThe information you provide will be used in accordance with the terms of our \u003Ca href=\"https:\/\/teladochealth.com\/en\/privacy-policy\/\" target=\"_blank\" class=\"mchNoDecorate\" style=\"display: inline;\"\u003Eprivacy policy\u003C\/a\u003E.\u003C\/small\u003E","IsLabelToLeft":true}],[{"Id":61185,"Name":"LeadSource","Datatype":"hidden","Maxlength":255,"InputLabel":"Lead Source:","InputInitialValue":"Marketing","InputSourceChannel":"constant","InputSourceSelector":"","ProfilingFieldNumber":0,"DisablePrefill":true}],[{"Id":61189,"Name":"Lead_Source_Detail__c","Datatype":"hidden","Maxlength":255,"InputLabel":"Lead Source Detail:","InputInitialValue":"Web Form","InputSourceChannel":"constant","InputSourceSelector":"","VisibleRows":4,"ProfilingFieldNumber":0}],[{"Id":61186,"Name":"utmsource","Datatype":"hidden","Maxlength":255,"InputLabel":"utm_source:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"utm_source","ProfilingFieldNumber":0}],[{"Id":61187,"Name":"utmcampaign","Datatype":"hidden","Maxlength":255,"InputLabel":"utm_campaign:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"utm_campaign","ProfilingFieldNumber":0}],[{"Id":61192,"Name":"utmcontent","Datatype":"hidden","Maxlength":255,"InputLabel":"utm_content:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"utm_content","ProfilingFieldNumber":0}],[{"Id":61193,"Name":"utmmedium","Datatype":"hidden","Maxlength":255,"InputLabel":"utm_medium:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"utm_medium","ProfilingFieldNumber":0}],[{"Id":61194,"Name":"GCLID__c","Datatype":"hidden","Maxlength":255,"InputLabel":"GCLID:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"gclid","ProfilingFieldNumber":0}],[{"Id":61195,"Name":"campaignid","Datatype":"hidden","Maxlength":255,"InputLabel":"campaign_id:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"campaign_id","ProfilingFieldNumber":0}],[{"Id":61196,"Name":"adid","Datatype":"hidden","Maxlength":255,"InputLabel":"ad_id:","InputInitialValue":"","InputSourceChannel":"url","InputSourceSelector":"ad_id","ProfilingFieldNumber":0}],[{"Id":61184,"Name":"Profiling","Datatype":"profiling","InputInitialValue":"","ProfilingFieldNumber":0,"IsLabelToLeft":true}]],"fieldsetRows":[],"action":null,"munchkinId":"138-DRH-707","dcJsUrl":"","invalidInputMsg":"Invalid Input","formSubmitFailedMsg":"Submission failed, please try again later."});