Biovance Ocular New Account Form .step-indicator { width: 100%; background: #E5E7EB; height: 8px; position: relative; } .step-progress { background: #2563EB; height: 8px; transition: width 0.5s ease-in-out; } @media (max-width: 768px) { .step-content { padding-bottom: 2rem; } form .grid { grid-template-columns: 1fr !important; } }

BIOVANCE® OCULAR NEW ACCOUNT FORM

Step 1

Step 2

Step 3

Step 4

Practice Information

Practice Name

Ship to Address

City

State

Zip Code

Office Phone

Product Code Select product code OCLR0010 - 10 mm disc OCLR0012 - 12 mm disc OCLR0015 - 15 mm disc OCLR1520 - 15 mm x 20 mm OCLR2525 - 25 mm x 25 mm OCLR3535 - 35 mm x 35 mm DHAM0010 - 10 mm disc DHAM00120 - 12 mm disc DHAM0015 - 15 mm disc DHAM0012 - 1 x 2 cm DHAM0022 - 2 x 2 cm

Quantity

Price

`; document.getElementById('products-container').insertAdjacentHTML('beforeend', productHTML); }); function updateStepIndicator() { document.getElementById('step-progress').style.width = `${(currentStep / 4) * 100}%`; document.getElementById('prevStep').disabled = currentStep === 1; document.getElementById('nextStep').textContent = currentStep === 4 ? 'Submit' : 'Next'; } document.querySelectorAll('input[name="sameAddress"]').forEach(radio => { radio.addEventListener('change', (e) => { if (e.target.value === 'no') { document.getElementById('billing-address').classList.remove('hidden'); } else { document.getElementById('billing-address').classList.add('hidden'); } }); }); document.getElementById('billing-terms-link').addEventListener('click', (e) => { e.preventDefault(); const finePrint = document.getElementById('fine-print'); finePrint.classList.toggle('hidden'); }); $(function() { $('#date').datepicker({ dateFormat: 'mm/dd/yy', showAnim: 'slideDown' }); });

BIOVANCE® OCULAR NEW ACCOUNT FORM

Practice Information

Billing Information

Product Selection

Review and Submit

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