{"id":157,"date":"2021-01-08T16:31:25","date_gmt":"2021-01-08T21:31:25","guid":{"rendered":"https:\/\/web.saumag.edu\/health\/?page_id=157"},"modified":"2021-01-26T10:02:26","modified_gmt":"2021-01-26T15:02:26","slug":"payment","status":"publish","type":"page","link":"https:\/\/web.saumag.edu\/health\/payment\/","title":{"rendered":"Fee Payment"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of 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class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_2'  action='\/health\/wp-json\/wp\/v2\/pages\/157' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_2_2\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_2_2'>\n                            \n                            <span id='input_2_2_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.3' id='input_2_2_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_2_2_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_2.6' id='input_2_2_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_2_2_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>SAU ID<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_2_8' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-product gfield--input-type-price gfield_price gfield_price_2_3 gfield_product_2_3 gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Custom Fee Amount<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_product_price'>\n\t\t\t\t\t<input name='input_3' id='input_2_3' type='text' value='' class='medium ginput_amount'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_2_3\" \/>\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_2_3'>Use this field to enter the total to be paid. <\/div><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-total gfield--input-type-total gfield_price gfield_price_2_ gfield_total gfield_total_2_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_2_9'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_9' id='input_2_9' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_2' \/>\n\t\t\t\t\t\t<\/div><\/div><fieldset id=\"field_2_6\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_2_6'><span class='ginput_full gform-grid-col' id='input_2_6_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_discover' >Discover<\/div><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_2_6_supported_creditcards'>Supported Credit Cards: Discover, MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_6.1' id='input_2_6_1' value=''   onchange='gformMatchCard(\"input_2_6_1\");' onkeyup='gformMatchCard(\"input_2_6_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_2_6_1' id='input_2_6_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_2_6_2_container'>\n                                            <fieldset class='ginput_cardinfo_left gform-grid-col' id='input_2_6_2_cardinfo_left'>\n                                            <legend class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/legend>\n                                                <span class='ginput_card_expiration_container ginput_card_field gform-grid-row'>\n                                                   <span class='ginput_card_expiration_month_container gform-grid-col'>\n                                                       <label for='input_2_6_2_month' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                                       <select name='input_6.2[]' id='input_2_6_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                   <span class='ginput_card_expiration_year_container gform-grid-col'>\n                                                       <label for='input_2_6_2_year' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                                       <select name='input_6.2[]' id='input_2_6_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2025' >2025<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option>\n                                                       <\/select>\n                                                   <\/span>\n                                                <\/span>\n                                            <\/fieldset><span class='ginput_cardinfo_right gform-grid-col' id='input_2_6_2_cardinfo_right'>\n                                                <input type='text' name='input_6.3' id='input_2_6_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_2_6_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_2_6_5_container'>\n                                            <input type='text' name='input_6.5' id='input_2_6_5' value=''    aria-required='false'  \/>\n                                            <label for='input_2_6_5' id='input_2_6_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                        <\/span> <\/div><\/fieldset><div id=\"field_2_14\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>CAPTCHA<\/label><div id='input_2_14' class='ginput_container ginput_recaptcha' data-sitekey='6LekhekSAAAAAE7EO1CGGm_hvOg0HlJHdRT9z6Lr'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_5'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_2_5' type='text' value='05\/20\/2025' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_10'>Transaction ID<\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_2_10' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_11'>Code<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_2_11' type='text' value='94661' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_12'>Description<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='UHS Fee' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_2_13'>Date<\/label><div class='ginput_container ginput_container_text'><input name='input_13' id='input_2_13' type='text' value='05\/20\/2025' class='medium'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Name<\/label><div class='ginput_container'><input name='input_15' id='input_2_15' type='text' value='' autocomplete='new-password'\/><\/div><div 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