< /iframe></noscript> <!-- End Google Tag Manager (noscript) --> <header> <div class="container"> <a href="/" class="logo" alt="Axonics logo"></a> <main class="container"> <div class="head"> <nav> <ul class="nav topmenu menu"> <li class="item-473"><a href="/corporate" >Corporate</a></li><li class="item-471"><a href="/hcp" >Healthcare Professionals</a></li><li class="item-472"><a href="/" >Patients</a></li></ul> </nav> <aside> <ul class="nav topmenu menu"> <li class="item-577"><a href="/hcp/resources/health-policy-resources" >Health Policy Resources</a></li><li class="item-475 current active"><a href="/contact-us" class="btn btn-contacts">Contact Us</a></li></ul> <div class="social"> <a href="https://www.facebook.com/axonics/" class="facebook" target="_blank" alt="Facebook"> <svg xmlns="http://www.w3.org/2000/svg" width="7.729" height="14.995" viewBox="0 0 7.729 14.995"> <path id="Path_47" data-name="Path 47" d="M0,0V-6.536H-2V-9.474H.046v-2.433s.091-3.064,2.718-3.088H5.687v2.883H3.873a.783.783,0,0,0-.764.864v1.823h2.62L5.416-6.483H3.155V0Z" transform="translate(2.001 14.995)" fill="#91959a"></path> </svg> </a> <a href="https://www.instagram.com/axonics/" class="instagram" target="_blank" alt="Instagram "> <svg xmlns="http://www.w3.org/2000/svg" width="15.429" height="15" viewBox="0 0 15.429 15"> <path id="Path_48" data-name="Path 48" d="M0,0H-11.571A1.9,1.9,0,0,1-13.5-1.875v-11.25A1.9,1.9,0,0,1-11.571-15H0a1.9,1.9,0,0,1,1.929,1.875v11.25A1.9,1.9,0,0,1,0,0M-5.786-9.4A1.932,1.932,0,0,0-7.744-7.5,1.932,1.932,0,0,0-5.786-5.6,1.933,1.933,0,0,0-3.827-7.5,1.933,1.933,0,0,0-5.786-9.4M0-13.125H-1.929v1.875H0ZM0-7.5H-1.687a4.042,4.042,0,0,1-4.1,3.984A4.041,4.041,0,0,1-9.884-7.5h-1.687v5.625H0Z" transform="translate(13.5 15)" fill="#91959a"></path> </svg> </a> <a href="https://www.youtube.com/channel/UCY3ELFd93I2Q47ijxIRioeg" class="youtube" target="_blank" alt="YouTube"> <svg xmlns="http://www.w3.org/2000/svg" width="14.73" height="15.015" viewBox="0 0 14.73 15.015"> <path id="Path_8618" data-name="Path 8618" d="M951.862,152.871h-5.917a4.407,4.407,0,0,0-4.407,4.407v6.2a4.407,4.407,0,0,0,4.407,4.407h5.917a4.407,4.407,0,0,0,4.407-4.407v-6.2A4.407,4.407,0,0,0,951.862,152.871Zm1.074,7.809-5.8,2.767a.233.233,0,0,1-.333-.21V157.53a.233.233,0,0,1,.338-.208l5.8,2.94A.233.233,0,0,1,952.936,160.68Z" transform="translate(-941.538 -152.871)" fill="#91959a"></path> </svg> </a> <a href="https://www.linkedin.com/company/axonics-modulation-technologies/" class="linkedin" target="_blank" alt="LinkedIn "> <svg xmlns="http://www.w3.org/2000/svg" width="15.015" height="14.07" viewBox="0 0 15.015 14.07"> <g id="Group_8789" data-name="Group 8789" transform="translate(0 0)"> <path id="Path_46" data-name="Path 46" d="M0,0V-5.687A1.689,1.689,0,0,0-1.64-7.208,1.786,1.786,0,0,0-3.381-5.762V0H-6.412l.05-9.4H-3.43l-.024,1.182A2.95,2.95,0,0,1-.538-9.754c2.3,0,3.346,1.32,3.538,3.794V0ZM-10.131-10.726a1.785,1.785,0,0,1-1.884-1.666,1.785,1.785,0,0,1,1.884-1.669,1.787,1.787,0,0,1,1.887,1.669,1.787,1.787,0,0,1-1.887,1.666M-8.257.009h-3.73V-9.372l3.73-.023Z" transform="translate(12.015 14.061)" fill="#91959a"></path> </g> </svg> </a> </div> </aside> </div> <nav> <a href="/" class="logo logo-menu"></a> <div class="burger-wrap"> <div class="text-burger"></div> <div class="burger"> <span></span> </div> </div> <ul class="nav menu mod-list"> <li class="item-476 deeper parent"><span class="nav-header ">About Axonics</span> <ul class="nav-child unstyled small"><li class="item-477"><a href="/about-axonics/who-we-are" >Who We Are</a></li><li class="item-479"><a href="/about-axonics/leadership" >Leadership</a></li></ul></li><li class="item-480 deeper parent"><span class="nav-header ">Investor Relations</span> <ul class="nav-child unstyled small"><li class="item-578"><a href="http://ir.axonics.com/" >Overview</a></li><li class="item-579"><a href="http://ir.axonics.com/news-releases" >News Releases</a></li><li class="item-580"><a href="http://ir.axonics.com/events-and-presentations/events" >Events and Presentation</a></li><li class="item-705"><a href="http://ir.axonics.com/corporate-governance/board-of-directors" title="Corporate Governance" class="Corporate Governance">Corporate Governance</a></li><li class="item-481"><a href="http://ir.axonics.com/stock-information/stock-quote-chart" >Stock Information</a></li><li class="item-482"><a href="http://ir.axonics.com/analyst-coverage" >Analyst Coverage</a></li><li class="item-483"><a href="http://ir.axonics.com/financial-information/sec-filings" >SEC Filings</a></li><li class="item-484"><a href="http://ir.axonics.com/investor-resources/investor-faqs" >Resources</a></li></ul></li><li class="item-486 deeper parent"><span class="nav-header ">Careers</span> <ul class="nav-child unstyled small"><li class="item-487"><a href="/careers/our-culture" >Our Culture</a></li><li class="item-489"><a href="/careers/employee-benefits" >Employee Benefits</a></li><li class="item-490"><a href="/careers/career" >Career Opportunities</a></li></ul></li><li class="item-535 current active"><a href="/contact-us" >Contact Us</a></li></ul> </nav> </main> </div> </header> <section class="totalheight"> <div class="custom-filter-block"> </div> <script> var sssText = ""; // var result = $('div.result'); setTimeout(function () { $('.custom-filter-block').insertBefore('.k2ItemsBlock'); }, 100); $(".btn-filter").click(function () { var dateLink = ""; var currentDate = '2023-12-06'; //this will find the selected website from the dropdown var go_to_url = $(".filter-select").find(":selected").val(); console.log("URL" + go_to_url); //this will redirect us in same window if (go_to_url === "2017") { var go_to_url = "&dtrange=range&sdate=2017-01-01&edate=2018-01-01" } else if (go_to_url === "2018") { var go_to_url = "&dtrange=range&sdate=2018-01-01&edate=2019-01-01" }else if (go_to_url === "2019") { var go_to_url = "&dtrange=range&sdate=2019-01-01&edate=2020-01-01" } else if (go_to_url === "2020") { var go_to_url = "&dtrange=range&sdate=2020-01-01&edate=2021-01-01" } else { var go_to_url = "&dtrange=range&sdate=2019-01-01&edate=2023-12-06" } // console.log(go_to_url); document.location.href = dateLink + go_to_url; }); </script> <style> .small-text { font-size: .75rem; font-weight: bold; } .cfb-flex { display: flex; align-items: flex-end; } .cfb-flex-2 { margin-left: 1.5rem; } .filter-select { font-size: 1rem; color: #939393; padding: .25rem .5rem; width: 400px; } .btn-filter { color: #555; font-weight: bold; cursor: pointer; } @media (max-width: 991px) { .cfb-flex { flex-direction: column; } .cfb-flex-1 { width: 100%; } .filter-select { width: 100%; } } </style> <div class="joomla-content"> <div id="system-message-container"> </div> <div class="item-page"> <div class="icons pull-right"> </div> <div class="blog-inner-social"></div> <section class="contact-us"> <div class="container"><br /><br /> <h1 class="green-text text-center" text-center="">Join the Inner Circle</h1> <p class="text-center">Join the Axonics<sup>®</sup> Inner Circle to receive updates and the latest news.</p> <p><!-- Begin Constant Contact Active Forms --> <script> var _ctct_m = "613e9a882264f13db4fb58f72108bce6"; </script> <script id="signupScript" src="//static.ctctcdn.com/js/signup-form-widget/current/signup-form-widget.min.js" async defer></script> <!-- End Constant Contact Active Forms --> <div style="max-width: 540px; border-radius: 3px; margin: 3rem auto; border: 1px solid #C0CCD9;"> <!-- Begin Constant Contact Inline Form Code --> <div class="ctct-inline-form" data-form-id="e9da654c-031a-4a75-a41e-bc5424a10562"></div> <!-- End Constant Contact Inline Form Code --> </div></p> </div> <style> fieldset, form, label, legend { margin: 0; padding: 0; border: 0; font-size: 100%; font: inherit; vertical-align: baseline; } small { font-size: .8em; } .quiz-layout { width: 100%; max-width: 960px; min-height: 517px; margin: 0 auto; padding: 1rem; background-color: #ffffff; color: #474e57; text-align: left; } .quiz-wrap form {} .quiz-wrap input[type="checkbox"], .quiz-wrap input[type="radio"] { margin: .25rem; } .quiz-wrap input[type="submit"] { width: 100%; font-size: 1rem; line-height: 1; margin-top: .5rem; padding: .5rem 1rem; border: 0px transparent; border-radius: .25rem; background-color: #474e57; color: #ffffff; font-weight: bold; cursor: pointer; } input[type="submit"]:hover { background-color: #6d737c; } .quiz-wrap .progress-bar { width: 100%; height: 5px; background-color: #e9e9e9; } .quiz-wrap .progress { height: 100%; background-color: #abd47d; width: 0; transition: width 0.2s ease-in-out; } .quiz-wrap fieldset { margin: 1rem 0 0; } .quiz-wrap fieldset legend { display: block; margin: 0 0 0.5rem; line-height: 1.2; } .quiz-wrap fieldset label { display: block; margin: 0 0 2px 0; line-height: 1; font-weight: bold; color: #ffffff; padding: .5rem; background-color: #474e57; border-radius: .25rem; } .quiz-wrap fieldset label:hover { background-color: #4f5761; user-select: none; cursor: pointer; transition: 0.1s ease-in; } .quiz-wrap fieldset label.label-selected { background-color: #6d737c; transition: 0.1s ease-in; } .quiz-wrap fieldset .btn-wrap { display: flex; justify-content: space-between; align-items: center; margin-top: .5rem; } .quiz-wrap button { font-weight: bold; font-size: 1rem; border: 0px none; background-color: transparent; background-size: 1rem; line-height: 1; background-repeat: no-repeat; border-radius: .25rem; } .quiz-wrap .backFieldset { color: #abd47d; background-image: url('/images/back-arrow.png'); padding: .5rem .5rem .5rem 1.75rem; background-position: .5rem .5rem; } .quiz-wrap .backFieldset:hover { background-color: #efefef; cursor: pointer; transition: 0.2s ease-in-out; } .quiz-wrap .nextFieldset { background-color: #abd47d; color: #ffffff; background-image: url('/images/next-arrow-white.png'); padding: .5rem 1.75rem .5rem .5rem; background-position: calc(100% - .5rem) .5rem; } .quiz-wrap .nextFieldset:hover { background-color: #bbe28f; cursor: pointer; transition: 0.2s ease-in-out; } .quiz-wrap .nextFieldset:disabled { visibility: hidden; } .survey-hidden-fields .group { background-color: #efefef; margin-top: .5rem; padding: .5rem; line-height: 1; } .survey-special { visibility: hidden; } .quiz-wrap span.input-label { display: inline-block; min-width: 180px; max-width: 50%; } .quiz-wrap span.input-label + input { min-width: 45%; } .quiz-wrap fieldset.survey-contact-details {} .quiz-wrap fieldset.survey-contact-details label, .quiz-wrap fieldset.survey-contact-details label:hover, .quiz-wrap fieldset.survey-contact-details label.label-selected { background-color: transparent; user-select: inherit; cursor: inherit; } .quiz-wrap fieldset.survey-contact-details label { font-size: .75rem; padding: 0; margin: 0; color: inherit; } .quiz-wrap fieldset.survey-contact-details label input { width: 100%; font-size: .85rem; padding: .25rem .5rem; border: 1px solid #cccccc; border-radius: .25rem; margin: .25rem 0 .5rem; } .privacy-modal { position: fixed; top: 0; left: 0; align-items: flex-start; justify-content: center; width: 100%; height: 100vh; background-color: rgb(0 0 0 / 59%); overflow: scroll; } .privacy-modal .modal-content { font-size: .75rem; display: block; background-color: #ffffff; width: auto; max-width: 720px; min-width: 300px; padding: 1.25rem 1.25rem; margin: 2rem auto; border-radius: 0.5rem; } .privacy-modal .modal-content h3 { font-size: 1rem; border-bottom: 1px solid gray; padding-bottom: .75rem; } .privacy-modal .modal-content p, .privacy-modal .modal-content ul li { font-size: inherit; } .privacy-modal.visible { display: flex !important; z-index: 999999; } @media only screen and (max-width: 900px) { html { font-size: 18px; } } @media only screen and (max-width: 570px) { html { font-size: 16px; } } </style> <div class="container" style="margin-top: 3rem;"> <h2 id="take-the-bladder-survey" style="text-align: center;">Take The Quiz. Find A Specialist.</h2> <!-- QUIZ --> <div class="quiz-layout"> <div class="quiz-wrap"> <div class="progress-bar"> <div class="progress"></div> </div> <form method="post" action="https://findrealrelief.axonics.com/surveys/quiz.php" onsubmit="return submitForm(this);"> <fieldset class="survey-bladder-symptoms"> <legend>Do you experience any of the following bowel and/or bladder control symptoms? <br><small>(Choose all that apply)</small></legend> <label for="frequentUrination"> <input type="checkbox" id="frequentUrination" name="bladder_symptoms[]" value="Frequent urination" autocomplete="off"> Frequent urination </label> <label for="strongUrge"> <input type="checkbox" id="strongUrge" name="bladder_symptoms[]" value="Sudden or strong urge to urinate" autocomplete="off"> Sudden or strong urge to urinate </label> <label for="leakageNoWarning"> <input type="checkbox" id="leakageNoWarning" name="bladder_symptoms[]" value="Urine leakage with little or no warning" autocomplete="off"> Urine leakage with little or no warning </label> <label for="leakageExertion"> <input type="checkbox" id="leakageExertion" name="bladder_symptoms[]" value="Urine leakage with exertion (eg, laughing, sneezing, exercise)" autocomplete="off"> Urine leakage with exertion (eg, laughing, sneezing, exercise) </label> <label for="incompleteEmptying"> <input type="checkbox" id="incompleteEmptying" name="bladder_symptoms[]" value="Incomplete emptying of the bladder" autocomplete="off"> Incomplete emptying of the bladder </label> <label for="bowelLeakage"> <input type="checkbox" id="bowelLeakage" name="bladder_symptoms[]" value="Bowel Leakage" autocomplete="off"> Bowel Leakage </label> <label for="noneOfTheAbove1"> <input type="checkbox" id="noneOfTheAbove1" name="bladder_symptoms[]" value="None of the above" autocomplete="off"> None of the above </label> <div class="btn-wrap"> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-bladder-symptoms-duration"> <legend>How long have you had bladder control symptoms?</legend> <label for="LessThan6Months" > <input type="radio" id="LessThan6Months" name="bladder_symptoms_duration" value="Less than 6 months" autocomplete="off"> Less than 6 months </label> <label for="6To12Months" > <input type="radio" id="6To12Months" name="bladder_symptoms_duration" value="6 to 12 months" autocomplete="off"> 6 to 12 months </label> <label for="Between1And5Years" > <input type="radio" id="Between1And5Years" name="bladder_symptoms_duration" value="Between 1 and 5 years" autocomplete="off"> Between 1 and 5 years </label> <label for="MoreThan5Years" > <input type="radio" id="MoreThan5Years" name="bladder_symptoms_duration" value="More than 5 years" autocomplete="off"> More than 5 years </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-quality-of-life"> <legend>How much do your bladder control symptoms affect your quality of life?</legend> <label for="verySeverely"> <input type="radio" id="verySeverely" name="quality_of_life" value="Very severely" autocomplete="off"> Very severely </label> <label for="severely"> <input type="radio" id="severely" name="quality_of_life" value="Severely" autocomplete="off"> Severely </label> <label for="moderately"> <input type="radio" id="moderately" name="quality_of_life" value="Moderately" autocomplete="off"> Moderately </label> <label for="slightly"> <input type="radio" id="slightly" name="quality_of_life" value="Slightly" autocomplete="off"> Slightly </label> <label for="noEffect"> <input type="radio" id="noEffect" name="quality_of_life" value="No effect" autocomplete="off"> No effect </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-has-doctor-diagnosed-you"> <legend>Has a doctor ever diagnosed you with any of the following? <br><small>(Choose all that apply)</small></legend> <label for="overactiveBladder"> <input type="checkbox" id="overactiveBladder" name="has_doctor_diagnosed_you[]" value="Overactive bladder (OAB)" autocomplete="off"> Overactive bladder (OAB) </label> <label for="urgeUrinaryIncontinence"> <input type="checkbox" id="urgeUrinaryIncontinence" name="has_doctor_diagnosed_you[]" value="Urge urinary incontinence (UUI)" autocomplete="off"> Urge urinary incontinence (UUI) </label> <label for="stressUrinaryIncontinence"> <input type="checkbox" id="stressUrinaryIncontinence" name="has_doctor_diagnosed_you[]" value="Stress urinary incontinence (SUI)" autocomplete="off"> Stress urinary incontinence (SUI) </label> <label for="urinaryRetention"> <input type="checkbox" id="urinaryRetention" name="has_doctor_diagnosed_you[]" value="Urinary retention (UR)" autocomplete="off"> Urinary retention (UR) </label> <label for="fecalIncontinence"> <input type="checkbox" id="fecalIncontinence" name="has_doctor_diagnosed_you[]" value="Fecal incontinence (FI)" autocomplete="off"> Fecal incontinence (FI) </label> <label for="noneOfTheAbove2"> <input type="checkbox" id="noneOfTheAbove2" name="has_doctor_diagnosed_you[]" value="None of the above" autocomplete="off"> None of the above </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-doctor-managing-issues"> <legend>Do you currently have a doctor managing your bladder control issues? <br><small>(If you have several, choose the one you consult most often.)</small></legend> <label for="primaryCareDoctor"> <input type="radio" id="primaryCareDoctor" name="doctor_managing_issues" value="Primary care doctor" autocomplete="off"> Primary care doctor </label> <label for="obgyn"> <input type="radio" id="obgyn" name="doctor_managing_issues" value="OB/GYN" autocomplete="off"> OB/GYN </label> <label for="urologist"> <input type="radio" id="urologist" name="doctor_managing_issues" value="Urologist" autocomplete="off"> Urologist </label> <label for="urogynecologist"> <input type="radio" id="urogynecologist" name="doctor_managing_issues" value="Urogynecologist" autocomplete="off"> Urogynecologist </label> <label for="anotherDoctor"> <input type="radio" id="anotherDoctor" name="doctor_managing_issues" value="Another doctor" autocomplete="off"> Another doctor </label> <label for="noDoctorAtThisTime"> <input type="radio" id="noDoctorAtThisTime" name="doctor_managing_issues" value="I don't have a doctor at this time" autocomplete="off"> I don't have a doctor at this time </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-tried-treatments"> <legend>Have you ever tried any of the following treatments? <br><small>(Choose all that apply)</small></legend> <label for="lifestyleChanges"> <input type="checkbox" id="lifestyleChanges" name="tried_treatments[]" value="Lifestyle changes (eg, dietary changes, limiting or timing fluid intake)" autocomplete="off"> Lifestyle changes (eg, dietary changes, limiting or timing fluid intake) </label> <label for="pelvicExercises"> <input type="checkbox" id="pelvicExercises" name="tried_treatments[]" value="Pelvic floor exercises or pelvic physical therapy" autocomplete="off"> Pelvic floor exercises or pelvic physical therapy </label> <label for="sacralNeuromodulation"> <input type="checkbox" id="sacralNeuromodulation" name="tried_treatments[]" value="Sacral neuromodulation (SNM, eg, Axonics or InterStim)" autocomplete="off"> Sacral neuromodulation (SNM, eg, Axonics or InterStim) </label> <label for="pelvicSling"> <input type="checkbox" id="pelvicSling" name="tried_treatments[]" value="Pelvic sling or other surgical procedure" autocomplete="off"> Pelvic sling or other surgical procedure </label> <label for="botoxOab"> <input type="checkbox" id="botoxOab" name="tried_treatments[]" value="BOTOX for OAB" autocomplete="off"> BOTOX injections </label> <label for="treatmentsNone"> <input type="checkbox" id="treatmentsNone" name="tried_treatments[]" value="None of the above" autocomplete="off"> None of the above </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-how-old-are-you"> <legend>How old are you?</legend> <label for="17orYounger"> <input type="radio" id="17orYounger" name="how_old_are_you" value="17 or younger" autocomplete="off"> 17 or younger </label> <label for="18to34"> <input type="radio" id="18to34" name="how_old_are_you" value="18 to 34" autocomplete="off"> 18 to 34 </label> <label for="35to49"> <input type="radio" id="35to49" name="how_old_are_you" value="35 to 49" autocomplete="off"> 35 to 49 </label> <label for="50to64"> <input type="radio" id="50to64" name="how_old_are_you" value="50 to 64" autocomplete="off"> 50 to 64 </label> <label for="65to79"> <input type="radio" id="65to79" name="how_old_are_you" value="65 to 79" autocomplete="off"> 65 to 79 </label> <label for="80orOlder"> <input type="radio" id="80orOlder" name="how_old_are_you" value="80 or older" autocomplete="off"> 80 or older </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-gender"> <legend>What is your sex, as assigned at birth?</legend> <label for="male"> <input type="radio" id="male" name="gender" value="Male" autocomplete="off"> Male </label> <label for="female"> <input type="radio" id="female" name="gender" value="Female" autocomplete="off"> Female </label> <label for="notSay"> <input type="radio" id="notSay" name="gender" value="I prefer not to say" autocomplete="off"> I prefer not to say </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-insurance"> <legend>What type of insurance do you have?</legend> <label for="privateInsurance"> <input type="radio" id="privateInsurance" name="insurance" value="Private insurance (either employer-provided or self-purchased)" autocomplete="off"> Private insurance (either employer-provided or self-purchased) </label> <label for="medicare"> <input type="radio" id="medicare" name="insurance" value="Medicare or Medicare Advantage" autocomplete="off"> Medicare or Medicare Advantage </label> <label for="medicaid"> <input type="radio" id="medicaid" name="insurance" value="Medicaid or government-assisted program" autocomplete="off"> Medicaid or government-assisted program </label> <label for="triCare"> <input type="radio" id="triCare" name="insurance" value="TriCare/Veterans Affairs" autocomplete="off"> TriCare/Veterans Affairs </label> <label for="noInsurance"> <input type="radio" id="noInsurance" name="insurance" value="No insurance/self-pay" autocomplete="off"> No insurance/self-pay </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-currently-taking-prescription"> <legend>Are you currently taking prescription bladder control medication(s)?</legend> <!-- "No, I’ve never taken them" should jump to "How did you hear about us?" --> <label for="prescriptionYes"> <input type="radio" id="prescriptionYes" name="currently_taking_prescription" value="Yes" autocomplete="off"> Yes </label> <label for="prescriptionTried"> <input type="radio" id="prescriptionTried" name="currently_taking_prescription" value="No, but I have tried them in the past" autocomplete="off"> No, but I have tried them in the past </label> <label for="prescriptionNo"> <input type="radio" id="prescriptionNo" name="currently_taking_prescription" value="No, I have never taken them" autocomplete="off"> No, I’ve never taken them </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-how-many-prescriptions-tried"> <legend>How many prescription bladder control medications have you tried?</legend> <label for="howManyOne"> <input type="radio" id="howManyOne" name="how_many_prescriptions_tried" value="One" autocomplete="off"> One </label> <label for="howManyTwo"> <input type="radio" id="howManyTwo" name="how_many_prescriptions_tried" value="Two" autocomplete="off"> Two </label> <label for="howManyThreeMore"> <input type="radio" id="howManyThreeMore" name="how_many_prescriptions_tried" value="Three or more" autocomplete="off"> Three or more </label> <label for="noneOfTheAbove3"> <input type="radio" id="noneOfTheAbove3" name="how_many_prescriptions_tried" value="None of the above" autocomplete="off"> None of the above </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="why-stop-taking-medication"> <legend>Why did you stop taking your bladder control medication? <br><small>(Choose all that apply)</small></legend> <label for="neverWorked"> <input type="checkbox" id="neverWorked" name="why_stopped_medications[]" value="Never worked" autocomplete="off"> Never worked </label> <label for="notWorkWellEnough"> <input type="checkbox" id="notWorkWellEnough" name="why_stopped_medications[]" value="Did not work well enough" autocomplete="off"> Did not work well enough </label> <label for="stoppedWorking"> <input type="checkbox" id="stoppedWorking" name="why_stopped_medications[]" value="Stopped working" autocomplete="off"> Stopped working </label> <label for="sideEffects"> <input type="checkbox" id="sideEffects" name="why_stopped_medications[]" value="Side effects"> Side effects </label> <label for="costInsuranceIssues"> <input type="checkbox" id="costInsuranceIssues" name="why_stopped_medications[]" value="Cost/insurance issues" autocomplete="off"> Cost/insurance issues </label> <label for="medicationOther"> <input type="checkbox" id="medicationOther" name="why_stopped_medications[]" value="Other" autocomplete="off"> Other </label> <label for="noneOfTheAbove4"> <input type="checkbox" id="noneOfTheAbove4" name="why_stopped_medications[]" value="None of the above" autocomplete="off"> None of the above </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="how-did-you-hear-about-us"> <legend>How did you hear about us? <br><small>(Choose all that apply)</small></legend> <label for="tvAd"> <input type="checkbox" id="tvAd" name="heard_about_us[]" value="TV ad " autocomplete="off"> TV ad </label> <label for="internetFacebookInstagram"> <input type="checkbox" id="internetFacebookInstagram" name="heard_about_us[]" value="Internet - Facebook/Instagram" autocomplete="off"> Internet - Facebook/Instagram </label> <label for="internetWebSearchBrowsing"> <input type="checkbox" id="internetWebSearchBrowsing" name="heard_about_us[]" value="Internet - Web Search/Browsing" autocomplete="off"> Internet - Web Search/Browsing </label> <label for="doctorRecommendation"> <input type="checkbox" id="doctorRecommendation" name="heard_about_us[]" value="Doctor recommendation" autocomplete="off"> Doctor recommendation </label> <label for="familyMemberFriend"> <input type="checkbox" id="familyMemberFriend" name="heard_about_us[]" value="Family member/friend" autocomplete="off"> Family member/friend </label> <label for="youTube"> <input type="checkbox" id="youTube" name="heard_about_us[]" value="YouTube" autocomplete="off"> YouTube </label> <label for="heardOther"> <input type="checkbox" id="heardOther" name="heard_about_us[]" value="Other" autocomplete="off"> Other </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="good-time-to-call"> <legend>When is a good time for us to call you with more information about physician providers in your area? <br><small>(Choose all that apply)</small></legend> <label for="RightNow"> <input type="checkbox" id="RightNow" name="time_to_call[]" value="Right now and weekday business hours only" autocomplete="off"> Right now (weekday business hours only) </label> <label for="CallMorning"> <input type="checkbox" id="CallMorning" name="time_to_call[]" value="Morning 8 to 11am" autocomplete="off"> Morning (8 – 11am) </label> <label for="CallMidday"> <input type="checkbox" id="CallMidday" name="time_to_call[]" value="Midday 11 to 2pm" autocomplete="off"> Midday (11 – 2pm) </label> <label for="CallAfternoon"> <input type="checkbox" id="CallAfternoon" name="time_to_call[]" value="Afternoon 2 to 5pm" autocomplete="off"> Afternoon (2 – 5pm) </label> <label for="IWillCall"> <input type="checkbox" id="IWillCall" name="time_to_call[]" value="No preference" autocomplete="off"> No preference </label> <div class="btn-wrap"> <button class="backFieldset">Back</button> <button class="nextFieldset" disabled>Next</button> </div> </fieldset> <fieldset style="display:none;" class="survey-contact-details"> <legend>You're almost done! Share your contact details to see if you qualify</legend> <label for="firstName"> <span>First Name:</span> <input type="text" id="firstName" name="firstName" required> </label> <label for="lastName"> <span>Last Name:</span> <input type="text" id="lastName" name="lastName" required> </label> <label for="email"> <span>Email:</span> <input type="email" id="email" name="email" required> </label> <label for="phone"> <span>Phone:</span> <input type="text" id="phone" name="phone" required> </label> <label for="zipCode"> <span>Zip Code:</span> <input type="text" id="zipCode" name="zipCode" autocomplete="off" required> </label> <small>By clicking ‘See if I qualify’, I agree to the terms of the <a href="https://www.axonics.com/privacy-policy" id="open-modal">Privacy Policy</a> and agree that Axonics may contact me to discuss my condition and potential treatments for it and will use my personal information for that purpose, consistent with the Privacy Policy.</small> <!-- <div class="g-recaptcha" data-sitekey="6LexCD8nAAAAACWPJTXQhBArsqJB_v-nAHXy4zH2"></div> <span class="error-message" id="captcha-error" style="display: none; color: red; font-size: 12px; position: absolute; margin-left: 15px;"></span> --> <div class="btn-wrap"> <input id="submit-btn" type="submit" value="See if I qualify"> </div> </fieldset> <!-- <div style="display:none;" class="survey-special"> <label for="special"> Special, pleaseomit. <input type="text" id="special" name="survey-special" value=""> </label> </div> --> <div style="display:none;" class="survey-hidden-fields"> <input type="hidden" id="thanks_content_check" name="thanks_content_check" value=""> <input type="hidden" id="quizCapturedUrl" name="quizCapturedUrl" value=""> <input type="hidden" id="quizQualifiedUrl" name="quizQualifiedUrl" value=""> <input type="hidden" id="referrer" name="referrer" value=""> <input type="hidden" id="utmVar" name="utmVar" value=""> <input type="hidden" id="googleClickID" name="googleClickID" value=""> <input type="hidden" id="facebookClickID" name="facebookClickID" value=""> <input type="hidden" id="microsoftClickID" name="microsoftClickID" value=""> </div> </form> </div> <!-- quiz-wrap --> </div> <!-- END QUIZ --> </div> <div class="privacy-modal" style="display:none;"> <div class="modal-content"> <h3>Axonics® Privacy Policy</h3> <p>Axonics, Inc. has created this Privacy Policy to document and demonstrate our firm commitment to privacy. This Privacy Policy describes the ways in which Axonics and its affiliates, service providers, and subsidiaries (collectively, “Axonics,” “we,” “our,” or “us”) may collect, use, and disclose personal information obtained or gathered through the use of Axonics websites or services that link to this policy (the “Services”). By using the Services and/or disclosing personal information, you consent to the processing of your personal information as set forth in this Privacy Policy, which is incorporated into our Terms of Use. This Privacy Statement is intended for website users in the United States. We will not sell the personal information that you provide to us.</p> <p><strong>What Information Do We Collect?</strong></p> <p>There are various places on the Axonics website where you can elect or sign-up to receive information from Axonics. We may collect the following categories of personal information about you in connection with your use of the Services:</p> <p><span style="text-decoration: underline;">Information You Provide</span>: We and our Service providers collect personal information that you may voluntarily share when you use the Services, including, but not limited to, information about your:</p> <ul> <li><span style="text-decoration: underline;">Contact information</span>, such as your first name, last name, email address, address, phone number;</li> <li><span style="text-decoration: underline;">Demographic information</span>, including your age, birth date, and gender;</li> <li><span style="text-decoration: underline;">Professional information</span>, including your employment status, employer information, title, occupation, and professional affiliations;</li> <li><span style="text-decoration: underline;">Account information</span>, including your username and password;</li> <li><span style="text-decoration: underline;">Health information</span>, including your health status, diagnoses, treatments, and symptoms;</li> </ul> <p><span style="text-decoration: underline;">Information Automatically Collected From You</span>: We and our service providers may automatically collect certain information about you and your online activities when you use the Services. We may collect personal and non-personal information, including, but not limited to, your Internet Protocol address, general geographic location, browser type, operating system, the pages you view on the Services, the pages you view immediately before and after you access the Services, links you follow on our website, and the search terms you enter on the Services.</p> <p><strong>How Do We Use Your Information?</strong></p> <p>We may use the information we collect for a number of purposes, including:</p> <ul> <li>to provide you with products, services, or information you request;</li> <li>to provide you with information about the Services or required notices;</li> <li>to deliver marketing communications, promotional materials, or advertisements that may be of interest to you;</li> <li>to customize your experience when using the Services, such as by providing interactive or personalized elements on the Services and providing you with content based on your interests;</li> <li>to improve the Services, such as by better tailoring our content to our users’ needs and preferences;</li> <li>to generate and analyze statistics about your use of the Services;</li> <li>to answer your questions about the Services, or otherwise communicate with you about the Services;</li> <li>for our business purposes, such as monitoring and prevention of fraud, intellectual property infringement, violations of our Terms of Use, violations of law, or other potential misuse of the Services.</li> </ul> <p><strong>When and to Whom Do We Disclose Your Information?</strong></p> <p>The information that we collect from and about you may be used internally by Axonics and may also be disclosed:</p> <ul> <li>to third parties that provide services to us in connection with our business operations and that have agreed to keep the information confidential;</li> <li>to business partners who offer products or services jointly with us or with our subsidiaries or affiliates;</li> <li>as required by law, such as to comply with a subpoena or other legal process, or to comply with government reporting obligations;</li> <li>when we believe in good faith that disclosure is necessary (a) to protect our rights, the integrity of the Services, or your safety or the safety of others, or (b) to detect, prevent, or respond to fraud, intellectual property infringement, violations of our Terms of Use, violations of law, or other misuse of the Services; and</li> <li>to service providers, advisors, potential transactional partners, or other third parties in connection with the consideration, negotiation, or completion of a corporate transaction in which we are acquired by or merged with another company or we sell, liquidate, or transfer all or a portion of our assets.</li> </ul> <p><strong>Use of Cookies</strong></p> To enable us to provide customized and personalized services, we and our service providers use cookies and similar tools to store and sometimes track information about you. A cookie is a small amount of data that is sent to your browser from a Web server and stored on your computer. If you do not want the Services to collect information through the use of cookies, you can set your web browser to reject cookies. Each browser is different, so you should check your browser’s “Help” menu to learn how to change your cookie preferences. If you reject or block cookies from the Services, however, the Services may not function as intended. <p><strong>Use of Google Analytics</strong></p> Google Analytics uses cookies to track your interactions with our website and online Services. Google then collects that information and reports it back to us. For more information on Google Analytics, visit “HOW GOOGLE USES INFORMATION FROM SITES OR APPS THAT USE OUR SERVICES” located at: https://www.google.com/policies/privacy/partners/. <p><strong>Do Not Track Signals</strong></p> California law requires that we share how we respond to website browser “do not track” signals. We do not currently recognize or honor “do not track” signals or other mechanisms that provide a method to opt out of the collection of information across websites or other online services. If we do so in the future, we will describe how we do so in this Privacy Policy. Visit the following website, www.allaboutdnt.org, for more information. <p><strong>Your California Privacy Rights</strong></p> If you reside in California and have provided your personally identifiable information to us, you may request information once per calendar year about our disclosures of certain categories of your personally identifiable information to third parties for their direct marketing purposes. Such requests must be submitted to us in writing at <span id="cloak1d1b7523f1e04827c6d939d8fb4265b4">This email address is being protected from spambots. You need JavaScript enabled to view it.</span><script type='text/javascript'> document.getElementById('cloak1d1b7523f1e04827c6d939d8fb4265b4').innerHTML = ''; var prefix = 'ma' + 'il' + 'to'; var path = 'hr' + 'ef' + '='; var addy1d1b7523f1e04827c6d939d8fb4265b4 = 'legal' + '@'; addy1d1b7523f1e04827c6d939d8fb4265b4 = addy1d1b7523f1e04827c6d939d8fb4265b4 + 'axonics' + '.' + 'com'; var addy_text1d1b7523f1e04827c6d939d8fb4265b4 = 'legal' + '@' + 'axonics' + '.' + 'com';document.getElementById('cloak1d1b7523f1e04827c6d939d8fb4265b4').innerHTML += '<a ' + path + '\'' + prefix + ':' + addy1d1b7523f1e04827c6d939d8fb4265b4 + '\'>'+addy_text1d1b7523f1e04827c6d939d8fb4265b4+'<\/a>'; </script>. <p><strong>Children's Information</strong></p> The Services are not intended for or directed to individuals under the age of thirteen (13). If a parent or guardian becomes aware that his or her child has directly provided us with personal information, please contact us by using the contact information below. <p><strong>Changes to This Privacy Policy</strong></p> We may update this Privacy Policy from time to time. If we update this Privacy Policy, we will notify you by posting a new Privacy Policy to this page. If we make a material change to our Privacy Policy, we will take reasonable steps to notify you, for example by posting a banner on the Services website, prior to putting the changes into effect. <p><strong>Contact Us</strong></p> <p>If you have any questions, please contact us at <span id="cloak510023e83a503a9c0c7cf1f96a5ec628">This email address is being protected from spambots. You need JavaScript enabled to view it.</span><script type='text/javascript'> document.getElementById('cloak510023e83a503a9c0c7cf1f96a5ec628').innerHTML = ''; var prefix = 'ma' + 'il' + 'to'; var path = 'hr' + 'ef' + '='; var addy510023e83a503a9c0c7cf1f96a5ec628 = 'legal' + '@'; addy510023e83a503a9c0c7cf1f96a5ec628 = addy510023e83a503a9c0c7cf1f96a5ec628 + 'axonics' + '.' + 'com'; var addy_text510023e83a503a9c0c7cf1f96a5ec628 = 'legal' + '@' + 'axonics' + '.' + 'com';document.getElementById('cloak510023e83a503a9c0c7cf1f96a5ec628').innerHTML += '<a ' + path + '\'' + prefix + ':' + addy510023e83a503a9c0c7cf1f96a5ec628 + '\'>'+addy_text510023e83a503a9c0c7cf1f96a5ec628+'<\/a>'; </script>.</p> <p><strong>Effective Date:</strong> July 8, 2019</p> </div> </div> <!-- <script src="https://www.google.com/recaptcha/api.js" async defer></script> --> <script> function checkThanksContent() { // Assuming the checkboxes have name attributes "bladder_symptoms[]" and "has_doctor_diagnosed_you[]" const bladderSymptoms = document.querySelectorAll('input[name="bladder_symptoms[]"]:checked'); const diagnosed = document.querySelectorAll('input[name="has_doctor_diagnosed_you[]"]:checked'); let hasRequiredBladderSymptom = false; let hasRequiredDiagnosis = false; bladderSymptoms.forEach(item => { if (item.value === "Urine leakage with exertion (eg, laughing, sneezing, exercise)") { hasRequiredBladderSymptom = true; } }); diagnosed.forEach(item => { if (item.value === "Stress urinary incontinence (SUI)" || item.value === "None of the above") { hasRequiredDiagnosis = true; } }); const thanksContentCheck = document.querySelector("#thanks_content_check"); if (hasRequiredBladderSymptom || hasRequiredDiagnosis) { thanksContentCheck.value = "true"; } else { thanksContentCheck.value = "false"; } } // Trim, hyphenate, and lower case a string function trimHyphenLower(str) { str = str.trim().replace(/\s+/g, '-').toLowerCase(); return str; } // Get Google Ad UTM Variables function utmPassAlong() { const pathArray = window.location.search.split('&'); let newPathname = ""; for (i = 0; i < pathArray.length; i++) { if (pathArray[i].startsWith("utm_")) { newPathname += "&"; newPathname += pathArray[i]; } } return newPathname; } // Cookie Functions function setCookie(cname,cvalue,exdays) { const d = new Date(); d.setTime(d.getTime() + (exdays*24*60*60*1000)); let expires = "expires=" + d.toUTCString(); document.cookie = cname + "=" + cvalue + ";" + expires + ";path=/"; } function getCookie(cname) { let name = cname + "="; let decodedCookie = decodeURIComponent(document.cookie); let ca = decodedCookie.split(';'); for(let i = 0; i < ca.length; i++) { let c = ca[i]; while (c.charAt(0) == ' ') { c = c.substring(1); } if (c.indexOf(name) == 0) { return c.substring(name.length, c.length); } } return ""; } // Set referrer cookie function referrerCookie() { let refCookie = getCookie("axnx_referrer_cookie"); if (refCookie === "" || refCookie === undefined) { let site = location.protocol + '//' + location.host let docRef = document.referrer; if (docRef.startsWith(site) || docRef === "") { setCookie("axnx_referrer_cookie", "direct", 30); } else { setCookie("axnx_referrer_cookie", docRef, 30); } } } // Set UTM cookie function utmCookie() { let utmCookie = getCookie("axnx_utm_cookie"); if (utmCookie === "" || utmCookie === undefined) { let utms = utmPassAlong(); setCookie("axnx_utm_cookie", utms, 30); } } function insertHiddenFields() { let quizCapturedUrlInput = document.querySelector('#quizCapturedUrl'); let quizQualifiedUrlInput = document.querySelector('#quizQualifiedUrl'); let referrerInput = document.querySelector('#referrer'); let utmVarInput = document.querySelector('#utmVar'); let googleClickIDInput = document.querySelector('#googleClickID'); let facebookClickIDInput = document.querySelector('#facebookClickID'); let microsoftClickIDInput = document.querySelector('#microsoftClickID'); let quizCapturedUrl = "?captured_url=" + location.protocol + "//" + location.host + location.pathname; let quizQualifiedUrl = "&qualified_url=" + "https://www.axonics.com/patients/qualified"; let utmVar = ""; if (getCookie("axnx_utm_cookie").length <= 1) { let utmSource = ""; // &utm_source=" + trimHyphenLower(""); let utmMedium = ""; // &utm_medium=" + trimHyphenLower(""); let utmCampaign = "&utm_campaign=" + trimHyphenLower("axonics.com/patients"); let utmContent = ""; // "&utm_content=" + trimHyphenLower("none"); let utmTerm = ""; // "&utm_term=" + trimHyphenLower("none"); utmVar = utmSource + utmMedium + utmCampaign + utmContent + utmTerm; } else { utmVar = getCookie("axnx_utm_cookie"); } let referrer = "&referrer=" + getCookie("axnx_referrer_cookie"); function getClickID(vendor) { const searchArray = window.location.search.split('&'); let resultsGCLID = ""; for (i = 0; i < searchArray.length; i++) { if(i === 0) { // console.log('searchArray[0] = ' + searchArray[0]); let firstSearch = searchArray[0].substring(1); if (firstSearch.startsWith(vendor)) { resultsGCLID = firstSearch; break; } } else { if (searchArray[i].startsWith(vendor)) { resultsGCLID = searchArray[i]; break; } } } // console.log("GCLID = " + resultsGCLID); return resultsGCLID; } let googleClickID = "&" + (getClickID("gclid") ? getClickID("gclid") : "blank"); let facebookClickID = "&" + (getClickID("fbclid") ? getClickID("fbclid") : "blank"); let microsoftClickID = "&" + (getClickID("msclkid") ? getClickID("msclkid") : "blank"); quizCapturedUrlInput.value = quizCapturedUrl.slice(1); quizQualifiedUrlInput.value = quizQualifiedUrl.slice(1); referrerInput.value = referrer.slice(1); utmVarInput.value = utmVar.slice(1); googleClickIDInput.value = googleClickID.slice(1); facebookClickIDInput.value = facebookClickID.slice(1); microsoftClickIDInput.value = microsoftClickID.slice(1); } document.addEventListener('DOMContentLoaded', function() { // add "label-selected" to any label with a checked radio input var radioInputs = document.querySelectorAll('input[type="radio"]'); for (var i = 0; i < radioInputs.length; i++) { radioInputs[i].addEventListener('change', function() { if (this.checked) { // remove "label-selected" class from all parent label elements in the same set var parentLabels = document.querySelectorAll('input[name="' + this.name + '"]'); for (var j = 0; j < parentLabels.length; j++) { parentLabels[j].parentNode.classList.remove('label-selected'); } // add "label-selected" class to the parent label element of the selected radio input var parentLabel = this.parentNode; parentLabel.classList.add('label-selected'); } }); } var fieldsets = document.querySelectorAll('fieldset'); // General 'next' function function nextStep(currentFieldset, steps = 1) { let nextFieldset = currentFieldset; for (let i = 0; i < steps; i++) { nextFieldset = nextFieldset.nextElementSibling; if (nextFieldset == null) break; } currentFieldset.style.display = 'none'; if (nextFieldset) nextFieldset.style.display = 'block'; // update progress bar var progressBar = document.querySelector('.progress'); var completed = document.querySelectorAll('fieldset:not([style*="none"])'); var index = Array.prototype.indexOf.call(fieldsets, nextFieldset); progressBar.style.width = ((index + 1) / fieldsets.length) * 100 + '%'; } // General 'back' function function previousStep(currentFieldset, steps = 1) { let prevFieldset = currentFieldset; for (let i = 0; i < steps; i++) { prevFieldset = prevFieldset.previousElementSibling; if (prevFieldset == null) break; } currentFieldset.style.display = 'none'; if (prevFieldset) prevFieldset.style.display = 'block'; // update progress bar var progressBar = document.querySelector('.progress'); var completed = document.querySelectorAll('fieldset:not([style*="none"])'); var index = Array.prototype.indexOf.call(fieldsets, prevFieldset); progressBar.style.width = (index / fieldsets.length) * 100 + '%'; } // "next" button functionality var nextButtons = document.querySelectorAll('.nextFieldset'); for (let i = 0; i < nextButtons.length; i++) { nextButtons[i].addEventListener('click', function(event) { event.preventDefault(); let current_fs = this.parentNode.parentNode; nextStep(current_fs); }); } // "previous" button functionality var prevButtons = document.querySelectorAll('.backFieldset'); for (let i = 0; i < prevButtons.length; i++) { prevButtons[i].addEventListener('click', function(event) { event.preventDefault(); let current_fs = this.parentNode.parentNode; previousStep(current_fs); }); } // Enable "next" button as soon as at least one checkbox or radio button is clicked within the current fieldset for (let i = 0; i < fieldsets.length; i++) { let checkboxes = fieldsets[i].querySelectorAll('input[type="checkbox"]'); let radioButtons = fieldsets[i].querySelectorAll('input[type="radio"]'); let nextButton = fieldsets[i].querySelector('.nextFieldset'); // for checkboxes, just enable the next button when at least one checkbox is checked for (let j = 0; j < checkboxes.length; j++) { checkboxes[j].addEventListener('change', function() { let hasChecked = Array.from(checkboxes).some(checkbox => checkbox.checked); if (hasChecked) { nextButton.disabled = false; } else { nextButton.disabled = true; } }); } // for radio buttons, enable the next button and move to the next fieldset when a radio button is selected for (let j = 0; j < radioButtons.length; j++) { if (radioButtons[j].id === 'prescriptionNo') continue; // Skip 'prescriptionNo' here, we handle it separately radioButtons[j].addEventListener('change', function() { nextButton.disabled = false; let current_fs = radioButtons[j].parentNode.parentNode; nextStep(current_fs); }); } } // If prescriptionNo is selected, skip 2 fieldsets var prescriptionNo = document.querySelector('#prescriptionNo'); var medTriedRadioNone = document.querySelector('#noneOfTheAbove3'); var medWhyStoppedRadioNone = document.querySelector('#noneOfTheAbove4'); if (prescriptionNo) { prescriptionNo.addEventListener('change', function(event) { if (event.target.checked) { let current_fs = this.parentNode.parentNode; // Inputs to set on skipped fieldsets medTriedRadioNone.checked = true; medWhyStoppedRadioNone.checked = true; nextStep(current_fs, 3); } }); } var openModalButton = document.getElementById('open-modal'); // var closeModalButton = document.getElementById('close-modal'); var modal = document.querySelector('.privacy-modal'); // show modal when "Open Modal" button is clicked openModalButton.addEventListener('click', function(event) { event.preventDefault(); modal.classList.add('visible'); }); // hide modal when "Close Modal" button is clicked modal.addEventListener('click', function(event) { event.preventDefault(); modal.classList.remove('visible'); }); }); referrerCookie(); utmCookie(); insertHiddenFields(); // function executeRecaptcha(form) { // return new Promise((resolve) => { // grecaptcha.ready(function() { // grecaptcha.execute('6LexCD8nAAAAACWPJTXQhBArsqJB_v-nAHXy4zH2', {action: 'submit'}).then(function(token) { // // Add the token to a hidden form input // var input = document.createElement('input'); // input.type = 'hidden'; // input.name = 'g-recaptcha-response'; // input.value = token; // form.appendChild(input); // // Resolve the promise when finished // resolve(); // }).catch(function(error) { // console.log("An error occurred while executing reCAPTCHA: ", error); // }); // }); // }); // } // Function to handle reCAPTCHA verification // function handleRecaptcha(form) { // // Check if reCAPTCHA checkbox is checked and verified // var recaptchaResponse = grecaptcha.getResponse(); // var captchaError = form.querySelector('#captcha-error'); // if (!recaptchaResponse || recaptchaResponse === "") { // captchaError.textContent = "Please complete the reCAPTCHA challenge."; // captchaError.style.display = "inline"; // return false; // Prevent form submission // } else { // captchaError.style.display = "none"; // return true; // Proceed with other logic in the submit function // } // } function validateForm(form) { var firstName = form.querySelector('#firstName'); var lastName = form.querySelector('#lastName'); var zipCode = form.querySelector('#zipCode'); var email = form.querySelector('#email'); var phone = form.querySelector('#phone'); var namePattern = /^[a-zA-Z\u00C0-\u017F-' ]+$/; var zipPattern = /^\d{5}$/; var emailPattern = /^[^\s@]+@[^\s@]+\.[^\s@]+$/; var phonePattern = /^[+]?[\s.-]?[(]?\d{3}[)]?[\s.-]?\d{3}[\s.-]?\d{4}$/; firstName.setCustomValidity(namePattern.test(firstName.value) ? "" : "Invalid input: The first name you entered is not in an accepted format."); lastName.setCustomValidity(namePattern.test(lastName.value) ? "" : "Invalid input: The last name you entered is not in an accepted format."); zipCode.setCustomValidity(zipPattern.test(zipCode.value) ? "" : "Invalid zip code. Zip code should only contain 5 digits."); email.setCustomValidity(emailPattern.test(email.value) ? "" : "Invalid email. Please check the format of your email."); phone.setCustomValidity(phonePattern.test(phone.value) ? "" : "Invalid phone number. Please use a 10-digit phone number."); return form.checkValidity(); } function submitForm(form) { var submitButton = form.querySelector('#submit-btn'); if (submitButton.getAttribute('data-processing') === 'true') { return false; } else { checkThanksContent(); // var isValid = (validateForm(form) && handleRecaptcha(form)); var isValid = (validateForm(form)); if (!isValid) { console.log("Form not valid."); return false; } submitButton.setAttribute('data-processing', 'true'); submitButton.disabled = true; // // reCaptcha: Call the executeRecaptcha function // executeRecaptcha(form).then(function() { // // Submit the form once the reCAPTCHA has been executed // form.submit(); // }); return true; } } var fields = ['firstName', 'lastName', 'zipCode', 'email', 'phone']; fields.forEach(function(fieldId) { var inputField = document.querySelector('#' + fieldId); inputField.addEventListener('input', function() { this.setCustomValidity(''); }); inputField.addEventListener('blur', function() { validateForm(this.form); }); }); </script> </section> <p><style type="text/css"> .cta-take-quiz { display: flex; position: fixed; z-index: 999; bottom: 13rem; right: -105px; width: 255px; background-color: #f2b459; color: #fff; padding: .5rem 1rem; transform: rotate(-90deg); font-size: .85em; border-radius: 5px 5px 0 0; } .cta-take-quiz:hover { transition: .2s; background-color: #fac577; } .cta-take-quiz a { cursor: pointer; } .cta-take-quiz a:hover { color: #fff; } @media screen and (max-width: 768px) { .cta-take-quiz { bottom: 0; right: 0; width: auto; transform: initial; } } </style> <div class="cta-take-quiz"> <a href="#take-the-bladder-survey" class="gtm--take-the-quiz"><span>Take The Quiz. Find A Specialist.</span></a> </div></p> </div> </div> <div class="custom" > <div class="block-questions container questions-other"> <article> <h2>Questions?</h2> <p>We are here to help answer any questions you may have about the Axonics System and Therapy.</p> </article> <div class="btn-block"><a class="btn btn-corporate" href="/contact-us">CONTACT US</a></div> </div></div> </section> <footer> <a href="/" class="logo"></a> <nav> <ul class="nav footermenu menu"> <li class="item-506"><a href="/corporate" >Corporate</a></li><li class="item-507"><a href="/hcp" >Healthcare Professionals</a></li><li class="item-637"><a href="/" >Patients</a></li></ul> </nav> <nav> <ul class="nav footermenu menu"> <li class="item-510"><a href="/about-axonics/who-we-are" >About Axonics</a></li><li class="item-512"><a href="http://ir.axonics.com/" >Investor Relations</a></li><li class="item-514"><a href="/careers/career" >Careers</a></li><li class="item-515 current active"><a href="/contact-us" >Contact Us</a></li></ul> </nav> <aside> <a href="#" class="btn btn-contacts btn-contacts--white-text">Contact Us</a> <div class="social"> <a href="https://www.facebook.com/axonics/" class="facebook" target="_blank"> <svg xmlns="http://www.w3.org/2000/svg" width="7.729" height="14.995" viewBox="0 0 7.729 14.995"> <path id="Path_47" data-name="Path 47" d="M0,0V-6.536H-2V-9.474H.046v-2.433s.091-3.064,2.718-3.088H5.687v2.883H3.873a.783.783,0,0,0-.764.864v1.823h2.62L5.416-6.483H3.155V0Z" transform="translate(2.001 14.995)" fill="#91959a"/> </svg> </a> <a href="https://www.instagram.com/axonics/" class="instagram" target="_blank"> <svg xmlns="http://www.w3.org/2000/svg" width="15.429" height="15" viewBox="0 0 15.429 15"> <path id="Path_48" data-name="Path 48" d="M0,0H-11.571A1.9,1.9,0,0,1-13.5-1.875v-11.25A1.9,1.9,0,0,1-11.571-15H0a1.9,1.9,0,0,1,1.929,1.875v11.25A1.9,1.9,0,0,1,0,0M-5.786-9.4A1.932,1.932,0,0,0-7.744-7.5,1.932,1.932,0,0,0-5.786-5.6,1.933,1.933,0,0,0-3.827-7.5,1.933,1.933,0,0,0-5.786-9.4M0-13.125H-1.929v1.875H0ZM0-7.5H-1.687a4.042,4.042,0,0,1-4.1,3.984A4.041,4.041,0,0,1-9.884-7.5h-1.687v5.625H0Z" transform="translate(13.5 15)" fill="#91959a"/> </svg> </a> <a href="https://www.youtube.com/channel/UCY3ELFd93I2Q47ijxIRioeg" class="youtube" target="_blank"> <svg xmlns="http://www.w3.org/2000/svg" width="14.73" height="15.015" viewBox="0 0 14.73 15.015"> <path id="Path_8618" data-name="Path 8618" d="M951.862,152.871h-5.917a4.407,4.407,0,0,0-4.407,4.407v6.2a4.407,4.407,0,0,0,4.407,4.407h5.917a4.407,4.407,0,0,0,4.407-4.407v-6.2A4.407,4.407,0,0,0,951.862,152.871Zm1.074,7.809-5.8,2.767a.233.233,0,0,1-.333-.21V157.53a.233.233,0,0,1,.338-.208l5.8,2.94A.233.233,0,0,1,952.936,160.68Z" transform="translate(-941.538 -152.871)" fill="#91959a"/> </svg> </a> <a href="https://www.linkedin.com/company/axonics-modulation-technologies/" class="linkedin" target="_blank"> <svg xmlns="http://www.w3.org/2000/svg" width="15.015" height="14.07" viewBox="0 0 15.015 14.07"> <g id="Group_8789" data-name="Group 8789" transform="translate(0 0)"> <path id="Path_46" data-name="Path 46" d="M0,0V-5.687A1.689,1.689,0,0,0-1.64-7.208,1.786,1.786,0,0,0-3.381-5.762V0H-6.412l.05-9.4H-3.43l-.024,1.182A2.95,2.95,0,0,1-.538-9.754c2.3,0,3.346,1.32,3.538,3.794V0ZM-10.131-10.726a1.785,1.785,0,0,1-1.884-1.666,1.785,1.785,0,0,1,1.884-1.669,1.787,1.787,0,0,1,1.887,1.669,1.787,1.787,0,0,1-1.887,1.666M-8.257.009h-3.73V-9.372l3.73-.023Z" transform="translate(12.015 14.061)" fill="#91959a"/> </g> </svg> </a> </div> </aside> <div> <div class="custom" > <p> </p> <p style="display: none;">©2020 Axonics Modulation Technologies, Inc. Axonics<sup>®</sup> and Axonics Modulation Technologies<sup>®</sup> are trademarks of Axonics Modulation Technologies, Inc., registered or pending registration in the U.S. and other countries.</p> <p>© 2020-2023 Axonics, Inc.</p></div> <ul class="nav footermenu menu-bottom"> <li class="item-531"><a href="/privacy-policy" >Privacy Policy</a></li><li class="item-532"><a href="/terms-of-use" >Terms of Use</a></li><li class="item-533"><a href="/important-safety-information" > Important Safety Information</a></li><li class="item-534"><a href="/sitemap" >Sitemap</a></li></ul> </div> </footer> <div class="latest-news-module"> </div> <!--<script type="text/javascript" src="/--><!--/js/swiper.min.js"></script>--> <script type="text/javascript" src="/templates/axonics/js/scripts.js"></script> <script type="text/javascript" src="/templates/axonics/js/scripts-joomla.js"></script> <script type="text/javascript" src="/templates/axonics/js/scripts-patients.js"></script> <script type="text/javascript" src="/templates/axonics/greg/scripts.js"></script> <!-- Go to www.addthis.com/dashboard to customize your tools --> <!-- <script type="text/javascript" src="//s7.addthis.com/js/300/addthis_widget.js#pubid=ra-5dcab1ef4ae41982"></script> --> <script> $(document).ready(function(){ /* var offset = $('#sidebar').offset(); $(window).scroll(function(e) { if((window.pageYOffset >= offset.top - 138) && ($('.bottomFooter').height()+350 < (($("header").height()+$(".hcp-mri-safety-compatibility").height()+$(".user-content").height()+$(".bottomFooter").height()) ) -window.pageYOffset)) { console.log('fire'); $('#sidebar').addClass('fixed'); $(".user-content").addClass('add_user_content'); } else { $('#sidebar').removeClass('fixed'); $('.user-content').removeClass('add_user_content'); $('#sidebar').addClass('removefixed'); } }); */ }); </script> </body> </html>