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<div class="control-group ticket_section"> <label class=" required control-label cf_date_of_incident_1287350-label " for="helpdesk_ticket_cf_date_of_incident_1287350">Date of Incident or Issue</label> <div class="controls support-date-field "> <input type="text" name="helpdesk_ticket[custom_field][cf_date_of_incident_1287350]" id="helpdesk_ticket_custom_field_cf_date_of_incident_1287350" class=" required date section_field datepicker_popover" readonly="readonly" data-show-image="true" data-date-format="d M, yy" placeholder="" /> </div> </div> <div class="control-group ticket_section"> <label class=" required control-label cf_area748961_1287350-label " for="helpdesk_ticket_cf_area748961_1287350">Which department or area of Blue Cross are you contacting us about?</label> <div class="controls nested_field "> <select class=" required nested_field section_field" id="helpdesk_ticket_custom_field_cf_area748961_1287350_76000096394" name="helpdesk_ticket[custom_field][cf_area748961_1287350]"><option value="">...</option> <option value="Veterinary Services">Veterinary Services</option> <option value="Rehoming">Rehoming</option> <option value="Shops or catalogue">Shops or catalogue</option> <option value="Community and Events">Community and Events</option> <option value="Vet Grant">Vet Grant</option> <option value="Fundraising and Communications">Fundraising and Communications</option> <option value="Behavioural Services">Behavioural Services</option> <option value="Education">Education</option> <option value="Volunteering">Volunteering</option> <option value="The Trustees and Directors">The Trustees and Directors</option> <option value="Supporter Care">Supporter Care</option> <option value="Other">Other</option></select><div class="level_2"><label class="required">Where did the incident happen or what did it involve?</label><select class=" required nested_field section_field" id="helpdesk_ticket_custom_field_cf_location_1287350_76000096394" name="helpdesk_ticket[custom_field][cf_location_1287350]"><option value="">...</option> </select></div><script> //<![CDATA[ jQuery('#helpdesk_ticket_custom_field_cf_area748961_1287350_76000096394').nested_select_tag({"data_tree":[["Veterinary Services","Veterinary Services",[["Ashford pet care clinic","Ashford pet care clinic",[]],["Cwmbran pet care clinic","Cwmbran pet care clinic",[]],["Derby pet care clinic","Derby pet care clinic",[]],["Grimsby hospital","Grimsby hospital",[]],["Hackney mobile clinic","Hackney mobile clinic",[]],["Hammersmith hospital","Hammersmith hospital",[]],["Highbury mobile clinic","Highbury mobile clinic",[]],["Islington mobile clinic","Islington mobile clinic",[]],["Luton pet care clinic","Luton pet care clinic",[]],["Merton animal hospital","Merton animal hospital",[]],["Southwark mobile clinic","Southwark mobile clinic",[]],["Torbay pet care clinic","Torbay pet care clinic",[]],["Victoria animal hospital","Victoria animal hospital",[]],["Walthamstow mobile clinic","Walthamstow mobile clinic",[]],["York pet care clinic","York pet care clinic",[]],["Unknown","Unknown",[]],["Vet care eligibility","Vet care eligibility",[]],["PawSquad","PawSquad",[]],["Flea and wormer subscription","Flea and wormer subscription",[]]]],["Rehoming","Rehoming",[["An online application","An online application",[]],["Andover","Andover",[]],["Barnstaple","Barnstaple",[]],["Boston","Boston",[]],["Bromsgrove","Bromsgrove",[]],["Burford","Burford",[]],["Cambridge","Cambridge",[]],["Chatham","Chatham",[]],["Cobham","Cobham",[]],["Durham","Durham",[]],["Epsom","Epsom",[]],["Greater Manchester","Greater Manchester",[]],["Grimsby","Grimsby",[]],["Ipswich","Ipswich",[]],["Kimpton","Kimpton",[]],["Lackham","Lackham",[]],["Lewisham","Lewisham",[]],["Lewknor","Lewknor",[]],["Middleton","Middleton",[]],["Moreton Morrell","Moreton Morrell",[]],["Myerscough","Myerscough",[]],["Newport","Newport",[]],["Paignton","Paignton",[]],["Rolleston (horses)","Rolleston (horses)",[]],["Rolleston","Rolleston",[]],["Sheffield","Sheffield",[]],["Solihull","Solihull",[]],["Southampton","Southampton",[]],["Swindon","Swindon",[]],["Thirsk","Thirsk",[]],["Tiverton","Tiverton",[]],["Torbay","Torbay",[]],["Usk","Usk",[]],["Wakefield","Wakefield",[]]]],["Shops or catalogue","Shops or catalogue",[["CATALOGUE","CATALOGUE",[]],["E Bay","E Bay",[]],["Abergavenny","Abergavenny",[]],["Andover","Andover",[]],["Banbury","Banbury",[]],["Bicester","Bicester",[]],["Bridgnorth","Bridgnorth",[]],["Bromsgrove","Bromsgrove",[]],["Cheltenham","Cheltenham",[]],["Chippenham","Chippenham",[]],["Chipping Norton","Chipping Norton",[]],["Chipping Sodbury","Chipping Sodbury",[]],["Cirencester","Cirencester",[]],["Droitwich","Droitwich",[]],["Dursley","Dursley",[]],["Egham","Egham",[]],["Farnham","Farnham",[]],["Fleet","Fleet",[]],["Frome","Frome",[]],["Halesowen","Halesowen",[]],["Haslemere","Haslemere",[]],["Harpenden","Harpenden",[]],["Heath Hayes","Heath Hayes",[]],["Hereford","Hereford",[]],["Hungerford","Hungerford",[]],["Kidlington","Kidlington",[]],["Leamington Spa","Leamington Spa",[]],["Ledbury","Ledbury",[]],["Lichfield","Lichfield",[]],["Ludlow","Ludlow",[]],["Malvern","Malvern",[]],["Manchester","Manchester",[]],["Marlborough","Marlborough",[]],["Monmouth","Monmouth",[]],["Nantwich","Nantwich",[]],["Newbury","Newbury",[]],["Pershore","Pershore",[]],["Shrewsbury","Shrewsbury",[]],["Solihull","Solihull",[]],["Stafford","Stafford",[]],["Stow","Stow",[]],["Stratford","Stratford",[]],["Teddington","Teddington",[]],["Tewkesbury","Tewkesbury",[]],["Thirsk","Thirsk",[]],["Trowbridge","Trowbridge",[]],["Walton On Thames","Walton On Thames",[]],["Warminster","Warminster",[]],["Warwick","Warwick",[]],["Wells","Wells",[]],["Weoley Castle","Weoley Castle",[]],["Weybridge","Weybridge",[]],["Wilmslow","Wilmslow",[]],["Witney","Witney",[]],["Wokingham","Wokingham",[]],["Worcester","Worcester",[]],["Yate","Yate",[]],["Yardley","Yardley",[]]]],["Community and Events","Community and Events",[["Local Event","Local Event",[]],["National Event","National Event",[]],["International Event","International Event",[]]]],["Vet Grant","Vet Grant",[]],["Fundraising and Communications","Fundraising and Communications",[["Blue Cross website","Blue Cross website",[]],["A fundraiser at my house","A fundraiser at my house",[]],["A fundraiser in a public space","A fundraiser in a public space",[]],["Email","Email",[]],["Event","Event",[]],["Facebook","Facebook",[]],["Lottery","Lottery",[]],["Mailing","Mailing",[]],["Pet sponsorship","Pet sponsorship",[]],["Raffle","Raffle",[]],["Telephone call","Telephone call",[]],["Text message","Text message",[]],["Other","Other",[]]]],["Behavioural Services","Behavioural Services",[]],["Education","Education",[["Pet Bereavement Support Service","Pet Bereavement Support Service",[]],["Education","Education",[]]]],["Volunteering","Volunteering",[]],["The Trustees and Directors","The Trustees and Directors",[]],["Supporter Care","Supporter Care",[]],["Other","Other",[]]],"initValues":null,"disable_children":false,"include_blank":"...","selected":null,"pl_value_id":"76000096394","subcategory_id":"helpdesk_ticket_custom_field_cf_location_1287350_76000096394"}); //]]> </script> </div> </div>
<div class="control-group ticket_section"> <label class=" required control-label cf_enquiry_subject_1287350-label " for="helpdesk_ticket_cf_enquiry_subject_1287350">What is your enquiry about</label> <div class="controls "> <select class=" required dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_enquiry_subject_1287350]" id="helpdesk_ticket_custom_field_cf_enquiry_subject_1287350"><option value="">...</option> <option data-id="76000149253" value="Communication preferences and contact details">Communication preferences and contact details</option> <option data-id="76000158757" value="Donation">Donation</option> <option data-id="76000149254" value="Adopting a pet from Blue Cross">Adopting a pet from Blue Cross</option> <option data-id="76000149255" value="Giving up a pet">Giving up a pet</option> <option data-id="76000151096" value="Pet advice">Pet advice</option> <option data-id="76000149634" value="Existing Blue Cross veterinary client">Existing Blue Cross veterinary client</option> <option data-id="76000220046" value="Pet behaviour">Pet behaviour</option> <option data-id="76000220043" value="Help with vet treatment">Help with vet treatment</option> <option data-id="76000220045" value="Retail">Retail</option> <option data-id="76000149635" value="Volunteering">Volunteering</option> <option data-id="76000220044" value="Working for Blue Cross">Working for Blue Cross</option> <option data-id="76000149636" value="Other">Other</option> <option data-id="76000223431" value="XL Bully">XL Bully</option></select> </div> </div>
<div class="control-group ticket_section"> <label class=" control-label cf_number_of_pets_species_3_1287350-label " for="helpdesk_ticket_cf_number_of_pets_species_3_1287350">Number of pets species 3</label> <div class="controls "> <input class=" number section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_number_of_pets_species_3_1287350]" id="helpdesk_ticket_custom_field_cf_number_of_pets_species_3_1287350" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_species_x4_1287350-label " for="helpdesk_ticket_cf_species_x4_1287350">Species x4</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_species_x4_1287350]" id="helpdesk_ticket_custom_field_cf_species_x4_1287350"><option value="">...</option> <option data-id="76000229777" value="N/A">N/A</option> <option data-id="76000229778" value="Dog">Dog</option> <option data-id="76000229779" value="Cat">Cat</option> <option data-id="76000229780" value="Rabbit">Rabbit</option> <option data-id="76000229781" value="Guinea Pig">Guinea Pig</option> <option data-id="76000229782" value="Hamster">Hamster</option> <option data-id="76000229783" value="Gerbil">Gerbil</option> <option data-id="76000229784" value="Degu">Degu</option> <option data-id="76000229785" value="Rat">Rat</option> <option data-id="76000229786" value="Chinchilla">Chinchilla</option> <option data-id="76000229787" value="Mouse">Mouse</option> <option data-id="76000229788" value="Ridden Horse/Pony">Ridden Horse/Pony</option> <option data-id="76000229789" value="Companion Horse/Pony">Companion Horse/Pony</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_number_of_pets_species_4_1287350-label " for="helpdesk_ticket_cf_number_of_pets_species_4_1287350">Number of pets </label> <div class="controls "> <input class=" number section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_number_of_pets_species_4_1287350]" id="helpdesk_ticket_custom_field_cf_number_of_pets_species_4_1287350" /> </div> </div>
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