{"html":"<div class=\"modal-body\">\n    <div class=\"row\">\n        <div class=\"col-sm-12\">\n            <div class=\"\">\n                <button type=\"button\" class=\"btn-close\" data-bs-dismiss=\"modal\" aria-label=\"Close\"><\/button>\n                <h3>Create Account<\/h3>\n                <form method=\"POST\" action=\"https:\/\/resources.macuhealth.com\/sign_up\/create\" class=\"custom-validation sign_up_form row g-3\" id=\"sign_up_form\" novalidate autocomplete=\"off\">\n                    <input type=\"hidden\" name=\"_token\" value=\"NROmbZaVAsr1M08T45etNTTW60ABiGd0JSUV0GZL\" autocomplete=\"off\">                    <div class=\"col-md-6\">\n                        <label for=\"first_name\" class=\"form-label\">First Name*<\/label>\n                        <input type=\"text\" class=\"form-control\" id=\"first_name\" name=\"first_name\" required minlength=\"4\" value=\"\" placeholder=\"Enter First Name\" data-parsley-pattern=\"^[A-Za-z]+$\" data-parsley-trigger=\"keyup\">\n                    <\/div>\n                    <div class=\"col-md-6\">\n                        <label for=\"last_name\" class=\"form-label\">Last Name*<\/label>\n                        <input type=\"text\" class=\"form-control\" id=\"last_name\" name=\"last_name\" required value=\"\" placeholder=\"Enter Last Name\" data-parsley-pattern=\"^[A-Za-z]+$\" data-parsley-trigger=\"keyup\">\n                    <\/div>\n                    <div class=\"col-md-6\">\n                        <label for=\"office\" class=\"form-label\">Company\/ Office*<\/label>\n                        <input type=\"text\" class=\"form-control\" id=\"office\" name=\"office\" required\n                        minlength=\"4\" value=\"\" placeholder=\"Enter Company \/ Office\">\n                    <\/div>\n                    <div class=\"col-md-6\">\n                        <label for=\"phone\" class=\"form-label\">Phone*<\/label>\n                        <input type=\"phone\" class=\"form-control digits\" id=\"phone\" name=\"phone\" required value=\"\" placeholder=\"Enter phone\" maxlength=\"10\" minlength=\"10\" data-parsley-pattern=\"^\\d{10}$\" data-parsley-trigger=\"keyup\">\n                    <\/div>\n                    <div class=\"col-md-6\">\n                        <label for=\"email\" class=\"form-label\">Email*<\/label>\n                        <input type=\"email\" class=\"form-control\" id=\"email\" name=\"email\" required minlength=\"4\" value=\"\" placeholder=\"Enter Email\" data-parsley-remote=\"https:\/\/resources.macuhealth.com\/check-email\" data-parsley-trigger=\"focusout\" data-parsley-remote-options='{ \"type\": \"GET\", \"dataType\": \"jsonp\", \"data\": { } }' data-parsley-remote-message=\"Email already in use!\">\n                    <\/div>\n                    <div class=\"col-md-6\">\n                        <label class=\"form-label\" for=\"password\">Password<\/label>\n                        <input type=\"password\" class=\"form-control eye_password\" id=\"password\" name=\"password\" required minlength=\"6\" placeholder=\"Enter Password\">\n                        <i class=\"toggle-password fa fa-fw fa-eye-slash\"><\/i>\n                    <\/div>\n                    <div class=\"col-md-12\">\n                      <label for=\"interested_product\" class=\"form-label\">Products are you interested in<\/label>\n                      <select class=\"form-control select2\" multiple=\"multiple\" id=\"interested_product\" name=\"interested_product[]\" placeholder=\"Select Products\">\n                                                    <option value=\"59\">Family of Products<\/option>\n                                                    <option value=\"60\">Canada<\/option>\n                                                    <option value=\"61\">LifeMeter<\/option>\n                                                    <option value=\"62\">MacuHealth<\/option>\n                                                    <option value=\"63\">MacuHealth+<\/option>\n                                                    <option value=\"64\">Vision Edge Pro<\/option>\n                                                    <option value=\"65\">VitreousHealth<\/option>\n                                                    <option value=\"66\">TG Omega-3<\/option>\n                                                    <option value=\"79\">MacuHealth DM<\/option>\n                                            <\/select>\n                    <\/div>\n                    <div class=\"col-12 show_notified\">\n                      <div class=\"form-check\">\n                        <input class=\"form-check-input\" type=\"checkbox\" id=\"notify_products\" name=\"notify_products\" value=\"true\">\n                        <label class=\"form-check-label\" for=\"notify_products\">I would like to be notified when new resources are available for your favorite products<\/label>\n                      <\/div>\n                    <\/div>\n                    <div class=\"col-12 text-center\">\n                      <button type=\"submit\" class=\"btn signIn_btn\">Sign up<\/button>\n                    <\/div>\n                    <div class=\"col-12 text-center\">\n                      <p class=\"form_content\">Already have an account? <a href=\"https:\/\/resources.macuhealth.com\/sign_in\" class=\"sign_in_btn_from_signup\">Login<\/a><\/p>\n                    <\/div>\n                  <\/form>\n            <\/div>\n        <\/div>\n    <\/div>\n<\/div>\n"}