Miniform Form Creator

Use this id in your miniform module (v0.10 and newer)
Tip: Click and drag the titles to change the order of the fields in your form

Contact and Appointment form

Items marked with star are required to answer. Attention screen reader users: The star will be read to you if you have some punctuation on in your screen reader.

The form

Below you find the form content you just generated.

Click on the "Copy" button - that becomes visible when you hover the code - to copy the content.

Paste the content in a textfile (use notepad.exe, NOT ms-word) and save it on your computer.

Name the file form_your_name.htt and upload it to the directory {website_root}/modules/miniform/templates/ on your webserver.

<div class="miniform">
	<div class="{MESSAGE_CLASS}">{STATUSMESSAGE}</div>
	<div class="{FORM_CLASS}">
		<small><CENTER><H1>Contact and Appointment form</center></h1>Items marked with star are required to answer.  Attention screen reader users:  The star will be read to you if you have some punctuation on in your screen reader.</small>
		<br/>
		<form name="form_{SECTION_ID}" id="form_{SECTION_ID}" method="post" action="{URL}" enctype="multipart/form-data">
			<input name="miniform" type="hidden" value="{SECTION_ID}"/>
			<input name="header" type="hidden" value="Berry&#039;s Advocates First Contact and Appointment Form"/>
			<input name="mf_timestamp" type="hidden" value="{DATE} {TIME}"/>
			<div  class="full">
				<label for="cupload"><span>Please upload no more than 5 pages describing the case.  Pleas no personal health data at this time. <span>*</span></span> 
					<input required="required" class="{CUPLOAD_ERROR}" type="file" id="cupload" name="mf_r_cupload" value="{CUPLOAD}" />
				</label>
			</div>
			<div  class="full">
				<label for="format"><span>What format best suits you?</span> 
					<select class="{FORMAT_ERROR}" id="format" name="mf_format">
						<option {FORMAT_SELECTED_BRAILLE_FILE+} value="Braille File+">Braille File+</option>
						<option {FORMAT_SELECTED_LARGE_PRINT+} value="Large Print+">Large Print+</option>
						<option {FORMAT_SELECTED_RECORDED_AUDIO} value="Recorded Audio">Recorded Audio</option>
					</select>
				</label>
			</div>
			<div  class="full">
				<label for="sa1"><span>Your Street Address please? <span>*</span></span> 
					<input placeholder="2222 Boogie boogie Avenue or Ave." required="required" class="{SA1_ERROR}" type="text" id="sa1" name="mf_r_sa1" value="{SA1}" />
				</label>
			</div>
			<div  class="full">
				<label for="sa2"><span>Apartment # please: <span>*</span></span> 
					<input placeholder="Apt. 3" required="required" class="{SA2_ERROR}" type="text" id="sa2" name="mf_r_sa2" value="{SA2}" />
				</label>
			</div>
			<div  class="full">
				<label for="c"><span>City please: <span>*</span></span> 
					<input placeholder="Worland" required="required" class="{C_ERROR}" type="text" id="c" name="mf_r_c" value="{C}" />
				</label>
			</div>
			<div  class="full">
				<label for="sc"><span>Please enter country or state (No abbreviations): <span>*</span></span> 
					<input placeholder="Arkansas or Honduras" required="required" class="{SC_ERROR}" type="text" id="sc" name="mf_r_sc" value="{SC}" />
				</label>
			</div>
			<div  class="full">
				<label for="zc"><span>Please enter five digit zip code or your country code? <span>*</span></span> 
					<input placeholder="59101 or Z29H4135B" required="required" class="{ZC_ERROR}" type="text" id="zc" name="mf_r_zc" value="{ZC}" />
				</label>
			</div>
			<div  class="full">
				<label for="p1"><span>Please enter your phone Number: <span>*</span></span> 
					<input placeholder="406-555-1212" required="required" class="{P1_ERROR}" type="text" id="p1" name="mf_r_p1" value="{P1}" />
				</label>
			</div>
			<div  class="full">
				<label for="vpn"><span>Please verify phone Number: <span>*</span></span> 
					<input placeholder="406-555-1212" required="required" class="{VPN_ERROR}" type="text" id="vpn" name="mf_r_vpn" value="{VPN}" />
				</label>
			</div>
			<div  class="full">
				<label for="e1"><span>Please enter your email: <span>*</span></span> 
					<input placeholder="foo@foobar.com" required="required" class="{E1_ERROR}" type="text" id="e1" name="mf_r_e1" value="{E1}" />
				</label>
			</div>
			<div  class="full">
				<label for="e2"><span>Please verify your email address for us: <span>*</span></span> 
					<input placeholder="foo@foobar.com" required="required" class="{E2_ERROR}" type="text" id="e2" name="mf_r_e2" value="{E2}" />
				</label>
			</div>
			<div  class="full">
				<label for="atime"><span>Please choose the time which works best for first appointment?</span> 
					<div class="grouping {ATIME_ERROR}">
						<input type="checkbox" id="i-atime1" {ATIME_8:00_TO_10:00_A.M.} name="mf_atime[]" value="8:00 to 10:00 A.M." /><label for="i-atime1">8:00 to 10:00 A.M.</label><br>
						<input type="checkbox" id="i-atime2" {ATIME_9:15_TO_11:15} name="mf_atime[]" value="9:15 to 11:15" /><label for="i-atime2">9:15 to 11:15</label><br>
						<input type="checkbox" id="i-atime3" {ATIME_12:20_TO_2:20} name="mf_atime[]" value="12:20 to 2:20" /><label for="i-atime3">12:20 to 2:20</label><br>
						<input type="checkbox" id="i-atime4" {ATIME_2:40_TO_4:40_P.M.} name="mf_atime[]" value="2:40 to 4:40 P.M." /><label for="i-atime4">2:40 to 4:40 P.M.</label>
						<input type="checkbox" id="i-atime5" {ATIME_3:00_TO_4:00_P.M.} name="mf_atime[]" value="3:00 to 4:00 P.M." /><label for="i-atime5">3:00 to 4:00 P.M.</label><br>
					</div>
				</label>
			</div>
			<div class="full">
				<button class="submit" name="Submit" type="submit">Submit to Berry&#039;s Advocating.</button>
			</div>
		</form>
	</div>
</div>

Use this form


Use the ID below to load the form in your Miniform module (version 0.10 or newer)