<pre class="source-code"></pre>
<form action='https://www.secure-booker.com/HeadsTurnLLC/WebToCustomer.aspx' method='POST' id='formd503ef40' onsubmit='javascript:submitd503ef40();'>
	<input type='hidden' id='OnSuccessUrl' name='OnSuccessUrl' value='https://www.htsaloncolumbus.com/'/>
	<input type='hidden' id='SpaID' name='SpaID' value='qLkr20CuTKdMQZ+u7UbnkQqT+q/4TG6gwsLEL0DH2H6K'/>
	<input type='hidden' id='RequiredFields' name='RequiredFields' value='FirstName,LastName,MobilePhone,Email'/>
	<table>	
	
<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='FirstNamed503ef40Label' for='FirstName'>First Name</label></td><td><input type='text' id='FirstName' name='FirstName' required maxlength='50'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='LastNamed503ef40Label' for='LastName'>Last Name</label></td><td><input type='text' id='LastName' name='LastName' required maxlength='50'/></td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='MobilePhoned503ef40Label' for='MobilePhone'>Mobile Phone</label></td><td><span><input type='text' id='MobilePhoned503ef40FullPhone' name='MobilePhone'  /></span>
<span>( <input type='text' id='MobilePhoned503ef40Phone1' maxlength='3' style='width:40px' /> ) <input type='text' id='MobilePhoned503ef40Phone2' maxlength='3' style='width:40px' /> - <input type='text' id='MobilePhoned503ef40Phone3' maxlength='4' style='width:50px' /></span>
</td></tr>

<tr><td><span style='color: #f00; margin: 0 3px;'>*</span><label id='Emaild503ef40Label' for='Email'>Email</label></td><td><input type='text' id='Email' name='Email' required maxlength='255'/></td></tr>

<tr><td><span style='color: transparent; margin: 0 3px;'>*</span><label id='AddressStreet1d503ef40Label' for='AddressStreet1'>Address Street 1</label></td><td><input type='text' id='AddressStreet1' name='AddressStreet1'  maxlength='100'/></td></tr>

<tr><td><span style='color: transparent; margin: 0 3px;'>*</span><label id='CustomField_63651d503ef40Label' for='CustomField_63651'>Instagram </label></td><td><textarea id='CustomField_63651' name='CustomField_63651'></textarea></td></tr>

	</table>
	<br/>
	<input type='submit' value='Save'/>
	<script type='text/javascript'>	
	
	var usaIdd503ef40 = 1;
	var canadaIdd503ef40 = 2;
	var phonesIdsd503ef40 = 'MobilePhoned503ef40';
	function ChangePhonesAndStatesd503ef40(updateFull){
		var obj = document.getElementById('AddressCountryd503ef40');
		var isNANPA = false;
		var currVal;
		if (obj && obj.value != ""){			
			currVal = obj.value;
		} else {
			currVal = 1;
		}
		isNANPA = usaIdd503ef40 == currVal || canadaIdd503ef40 == currVal;
		var phones = phonesIdsd503ef40.split(';');
		for(var i=0;i<phones.length;i++){
			if (!document.getElementById(phones[i] + 'FullPhone')){
				break;
			}
			if (isNANPA){
				document.getElementById(phones[i] + 'Phone1').parentNode.style.display = 'inline';
				document.getElementById(phones[i] + 'FullPhone').parentNode.style.display = 'none';
			} else {
				document.getElementById(phones[i] + 'FullPhone').parentNode.style.display = 'inline';
				document.getElementById(phones[i] + 'Phone1').parentNode.style.display = 'none';
			}
			if (updateFull && isNANPA){			
				document.getElementById(phones[i] + 'FullPhone').value = document.getElementById(phones[i] + 'Phone1').value + document.getElementById(phones[i] + 'Phone2').value + document.getElementById(phones[i] + 'Phone3').value;
			}

		}

		// update states list
		var statesObj = document.getElementById('AddressStated503ef40');
		if (statesObj != null) {
			var statesLabelObj = document.getElementById('AddressStated503ef40Label');
			var isUS = obj.value != '' && usaIdd503ef40 == currVal;
			statesObj.style.display = isUS ? '' : 'none';
			statesLabelObj.style.display = isUS ? '' : 'none';
			if (isUS){
				// we select the first item - Any state
				statesObj.options[0].selected = true;
			}
		}

	}

	ChangePhonesAndStatesd503ef40(false);

	function submitd503ef40(){
		ChangePhonesAndStatesd503ef40(true);
	}
	
	</script>
</form>