1. System Generated Field Panel
2. Author Entered Field Panel
3. Form Title Panel
4. End-user Entered Field Panel
5. Thank You and Error Message Panel
6. Hidden Panel

• System Generated Field Panel
• Author Entered Field Panel
• Form Title Panel
• End-user Entered Field Panel
• Thank You and Error Message Panel
• Hidden Panel

System Generated Panel 

Market Region

Market Region ASIA APAC EMEA LATAM

*Nation / Country Bangladesh Australia Hongkong United Kingdom Turkey Kuwait Bahrain Egypt Jordan Greece Oman Lebanon Romania Bulgaria France Poland Portugal Spain UAE Italy Russia Portugal Argentina Columbia Brazil

User Date

Enable Captcha

SendUserEmail

Email Template for Recipient

Acknowledgement Email Template

Attachment Information

 Author Input Panel

Author Input Panel - Required fields

*Type of Form Integration siteComponent slider contactCardForm

analytics form Title

Analytics form type

*Type Of Form Contactform Inquiry Grievance

CC Email address to which form data will be sent

Subject line of the email

Subject line of the Acknowledgement

File Upload Messages Configuration

Virus Scan in Progress

File Size Limit Error

Virus Found Message

Invalid File Type Error message

File Count

Upload More

Service Down

Form Title  Panel

Provider Nomination Form

User Input Panel

Please complete this form to nominate an International Provider for direct settlement.

Part A: Member Information

*Your Name

*City

*Country

*Email

*Employer Name

Part B: Provider Information

*Hospital / Clinic Name

*City

*Country

*Address

*Hospital Contact

*Title

*Telephone

*Number of Annual Visits

*Email

*Additional Comments

Are you a provider looking to join our network? Fill out our provider submission form to give us all your details.

  

SUBMIT

Thank You/Error Panel Configuration

Message Option Same page-fadeout Same page-fixed New page

Settings for same page thank you/error message

Message Delay

Error

An Error has occurred during form submission. Please try again.

Thank You

Your request has been received.

Settings for separate page thank you/error message

Error Page

Thank You Page

Page Target

Page Target Same Tab New Tab

Hidden Panel

Name Of The Template