Form Pendaftaran - Bingxue Smile Project<\/title>\r\n <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Poppins:wght@300;400;500;600;700&display=swap\" rel=\"stylesheet\">\r\n <style>\r\n * {\r\n margin: 0;\r\n padding: 0;\r\n box-sizing: border-box;\r\n }\r\n\r\n body {\r\n font-family: 'Poppins', sans-serif;\r\n line-height: 1.6;\r\n color: #333;\r\n background: #f8f9fa;\r\n }\r\n\r\n .container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n padding: 20px;\r\n }\r\n\r\n .form-header {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 40px 30px;\r\n border-radius: 15px 15px 0 0;\r\n text-align: center;\r\n }\r\n\r\n .form-header h1 {\r\n font-size: 2em;\r\n margin-bottom: 10px;\r\n font-weight: 700;\r\n }\r\n\r\n .form-header p {\r\n font-size: 1em;\r\n opacity: 0.95;\r\n font-weight: 400;\r\n }\r\n\r\n .form-container {\r\n background: white;\r\n padding: 40px;\r\n border-radius: 0 0 15px 15px;\r\n box-shadow: 0 4px 15px rgba(0,0,0,0.1);\r\n }\r\n\r\n .form-section {\r\n margin-bottom: 35px;\r\n }\r\n\r\n .section-title {\r\n font-size: 1.3em;\r\n font-weight: 600;\r\n color: #f0832c;\r\n margin-bottom: 20px;\r\n padding-bottom: 10px;\r\n border-bottom: 2px solid #f0832c;\r\n }\r\n\r\n .form-group {\r\n margin-bottom: 20px;\r\n }\r\n\r\n .form-group label {\r\n display: block;\r\n font-weight: 500;\r\n margin-bottom: 8px;\r\n color: #333;\r\n font-size: 0.95em;\r\n }\r\n\r\n .required {\r\n color: #d63638;\r\n font-weight: 700;\r\n }\r\n\r\n .form-group input[type=\"text\"],\r\n .form-group input[type=\"number\"],\r\n .form-group select,\r\n .form-group textarea {\r\n width: 100%;\r\n padding: 12px 15px;\r\n border: 2px solid #e0e0e0;\r\n border-radius: 8px;\r\n font-size: 1em;\r\n font-family: 'Poppins', sans-serif;\r\n transition: border-color 0.3s;\r\n }\r\n\r\n .form-group input:focus,\r\n .form-group select:focus,\r\n .form-group textarea:focus {\r\n outline: none;\r\n border-color: #f0832c;\r\n }\r\n\r\n .form-group textarea {\r\n resize: vertical;\r\n min-height: 100px;\r\n }\r\n\r\n .form-row {\r\n display: grid;\r\n grid-template-columns: 1fr 1fr;\r\n gap: 20px;\r\n }\r\n\r\n .file-upload-area {\r\n border: 2px dashed #f0832c;\r\n padding: 30px;\r\n text-align: center;\r\n border-radius: 8px;\r\n cursor: pointer;\r\n transition: background-color 0.3s;\r\n position: relative;\r\n }\r\n\r\n .file-upload-area:hover {\r\n background-color: #fff5ef;\r\n }\r\n\r\n .file-upload-area input[type=\"file\"] {\r\n position: absolute;\r\n width: 100%;\r\n height: 100%;\r\n top: 0;\r\n left: 0;\r\n opacity: 0;\r\n cursor: pointer;\r\n }\r\n\r\n .file-upload-icon {\r\n font-size: 2.5em;\r\n color: #f0832c;\r\n margin-bottom: 10px;\r\n }\r\n\r\n .file-upload-text {\r\n color: #666;\r\n font-size: 0.95em;\r\n }\r\n\r\n .file-name-display {\r\n margin-top: 10px;\r\n padding: 10px;\r\n background: #e3f2fd;\r\n border-radius: 5px;\r\n color: #1976d2;\r\n font-weight: 500;\r\n display: none;\r\n }\r\n\r\n .help-text {\r\n font-size: 0.85em;\r\n color: #666;\r\n margin-top: 5px;\r\n font-style: italic;\r\n }\r\n\r\n .btn-submit {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 15px 50px;\r\n border: none;\r\n border-radius: 50px;\r\n font-size: 1.1em;\r\n font-weight: 600;\r\n font-family: 'Poppins', sans-serif;\r\n cursor: pointer;\r\n width: 100%;\r\n transition: all 0.3s;\r\n box-shadow: 0 4px 15px rgba(240, 131, 44, 0.3);\r\n }\r\n\r\n .btn-submit:hover {\r\n transform: translateY(-2px);\r\n box-shadow: 0 6px 20px rgba(240, 131, 44, 0.4);\r\n }\r\n\r\n .btn-submit:disabled {\r\n opacity: 0.6;\r\n cursor: not-allowed;\r\n transform: none;\r\n }\r\n\r\n .loading {\r\n display: none;\r\n text-align: center;\r\n padding: 20px;\r\n }\r\n\r\n .loading-spinner {\r\n border: 3px solid #f3f3f3;\r\n border-top: 3px solid #f0832c;\r\n border-radius: 50%;\r\n width: 40px;\r\n height: 40px;\r\n animation: spin 1s linear infinite;\r\n margin: 0 auto 10px;\r\n }\r\n\r\n @keyframes spin {\r\n 0% { transform: rotate(0deg); }\r\n 100% { transform: rotate(360deg); }\r\n }\r\n\r\n \/* Modal Popup Styles *\/\r\n .modal-overlay {\r\n display: none;\r\n position: fixed;\r\n top: 0;\r\n left: 0;\r\n width: 100%;\r\n height: 100%;\r\n background: rgba(0, 0, 0, 0.6);\r\n z-index: 9998;\r\n animation: fadeIn 0.3s;\r\n }\r\n\r\n .modal {\r\n display: none;\r\n position: fixed;\r\n top: 50%;\r\n left: 50%;\r\n transform: translate(-50%, -50%);\r\n background: white;\r\n border-radius: 12px;\r\n box-shadow: 0 10px 40px rgba(0,0,0,0.3);\r\n z-index: 9999;\r\n width: 350px !important;\r\n max-width: 90% !important;\r\n animation: slideIn 0.3s;\r\n overflow: hidden;\r\n }\r\n\r\n @keyframes fadeIn {\r\n from { opacity: 0; }\r\n to { opacity: 1; }\r\n }\r\n\r\n @keyframes slideIn {\r\n from {\r\n opacity: 0;\r\n transform: translate(-50%, -60%);\r\n }\r\n to {\r\n opacity: 1;\r\n transform: translate(-50%, -50%);\r\n }\r\n }\r\n\r\n .modal-header {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 15px !important;\r\n text-align: center;\r\n display: flex !important;\r\n align-items: center !important;\r\n justify-content: center !important;\r\n }\r\n\r\n .modal-icon {\r\n font-size: 2em;\r\n margin-bottom: 5px;\r\n display: block;\r\n }\r\n\r\n .modal-header h2 {\r\n font-size: 1em;\r\n font-weight: 700;\r\n margin: 0;\r\n font-family: 'Poppins', sans-serif;\r\n text-align: center !important;\r\n width: 100% !important;\r\n }\r\n\r\n .modal-body {\r\n padding: 20px 15px !important;\r\n text-align: center;\r\n }\r\n\r\n .modal-message {\r\n font-size: 0.9em;\r\n color: #333;\r\n line-height: 1.4;\r\n margin-bottom: 15px;\r\n font-weight: 400;\r\n font-family: 'Poppins', sans-serif;\r\n }\r\n\r\n .modal-btn {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 10px 30px;\r\n border: none;\r\n border-radius: 8px;\r\n font-size: 0.9em;\r\n font-weight: 600;\r\n font-family: 'Poppins', sans-serif;\r\n cursor: pointer;\r\n transition: all 0.3s;\r\n box-shadow: 0 3px 10px rgba(240, 131, 44, 0.3);\r\n }\r\n\r\n .modal-btn:hover {\r\n transform: translateY(-2px);\r\n box-shadow: 0 6px 20px rgba(240, 131, 44, 0.4);\r\n }\r\n\r\n .modal-error .modal-header {\r\n background: linear-gradient(135deg, #dc3545 0%, #c82333 100%);\r\n }\r\n\r\n .modal-error .modal-btn {\r\n background: linear-gradient(135deg, #dc3545 0%, #c82333 100%);\r\n box-shadow: 0 4px 15px rgba(220, 53, 69, 0.3);\r\n }\r\n\r\n .modal-error .modal-btn:hover {\r\n box-shadow: 0 6px 20px rgba(220, 53, 69, 0.4);\r\n }\r\n\r\n @media (max-width: 768px) {\r\n .form-header h1 {\r\n font-size: 1.5em;\r\n }\r\n\r\n .form-container {\r\n padding: 25px;\r\n }\r\n\r\n .form-row {\r\n grid-template-columns: 1fr;\r\n }\r\n\r\n .modal {\r\n max-width: 90%;\r\n }\r\n\r\n .modal-header h2 {\r\n font-size: 1.3em;\r\n }\r\n\r\n .modal-icon {\r\n font-size: 2.5em;\r\n }\r\n\r\n .modal-message {\r\n font-size: 0.95em;\r\n }\r\n }\r\n <\/style>\r\n<\/head>\r\n<body>\r\n <div class=\"container\">\r\n <div class=\"form-header\">\r\n <h1>Form Pendaftaran<\/h1>\r\n <p>Bingxue Smile Project - Operasi Bibir Sumbing Gratis<\/p>\r\n <\/div>\r\n\r\n <div class=\"form-container\">\r\n \r\n <div id=\"loading\" class=\"loading\">\r\n <div class=\"loading-spinner\"><\/div>\r\n <p>Mengirim data pendaftaran...<\/p>\r\n <\/div>\r\n\r\n <form id=\"bingxue-form\" enctype=\"multipart\/form-data\" action=\"\">\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Data Anak (Pasien)<\/h2>\r\n \r\n <div class=\"form-row\">\r\n <div class=\"form-group\">\r\n <label>Nama Lengkap Anak <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" name=\"nama_anak\" required placeholder=\"Nama lengkap sesuai akta kelahiran\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Umur Anak (tahun) <span class=\"required\">*<\/span><\/label>\r\n <input type=\"number\" name=\"umur_anak\" required min=\"0\" max=\"18\" placeholder=\"Contoh: 2\">\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Berat Badan Anak (kg) <span class=\"required\">*<\/span><\/label>\r\n <input type=\"number\" name=\"berat_badan\" required step=\"0.1\" min=\"0\" max=\"100\" placeholder=\"Contoh: 5.5\">\r\n <p class=\"help-text\">Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Data Orang Tua \/ Wali<\/h2>\r\n \r\n <div class=\"form-group\">\r\n <label>Nama Orang Tua\/Wali <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" name=\"nama_orangtua\" required placeholder=\"Nama ayah\/ibu\/wali\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Nomor HP\/WhatsApp <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" name=\"nomor_hp\" required placeholder=\"08xx xxxx xxxx\">\r\n <p class=\"help-text\">Pastikan nomor aktif untuk dihubungi tim kami<\/p>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Alamat Lengkap <span class=\"required\">*<\/span><\/label>\r\n <textarea name=\"alamat\" required placeholder=\"Jalan, RT\/RW, Kelurahan, Kecamatan, Kota\/Kabupaten, Provinsi, Kode Pos\"><\/textarea>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Kondisi Medis<\/h2>\r\n \r\n <div class=\"form-group\">\r\n <label>Jenis Sumbing <span class=\"required\">*<\/span><\/label>\r\n <select name=\"jenis_sumbing\" required>\r\n <option value=\"\">-- Pilih Jenis Sumbing --<\/option>\r\n <option value=\"Bibir Sumbing Saja\">Bibir Sumbing Saja<\/option>\r\n <option value=\"Celah Langit-Langit Saja\">Celah Langit-Langit Saja<\/option>\r\n <option value=\"Bibir Sumbing dan Celah Langit-Langit\">Bibir Sumbing dan Celah Langit-Langit<\/option>\r\n <\/select>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Upload Dokumen<\/h2>\r\n \r\n <div class=\"form-group\">\r\n <label>Foto Bibir\/Langit-Langit Anak <span class=\"required\">*<\/span><\/label>\r\n <div class=\"file-upload-area\">\r\n <div class=\"file-upload-text\">\r\n <strong>Klik untuk upload foto<\/strong><br>\r\n Format: JPG, PNG (Maksimal 5MB)\r\n <\/div>\r\n <input type=\"file\" id=\"foto_sumbing\" name=\"foto_sumbing\" accept=\"image\/jpeg,image\/jpg,image\/png\" required onchange=\"displayFileName(this, 'foto-display')\">\r\n <\/div>\r\n <div id=\"foto-display\" class=\"file-name-display\"><\/div>\r\n <p class=\"help-text\">Upload foto tampak depan dengan kepala mengadah ke atas dan mulut terbuka<\/p>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Rekam Medis (Opsional)<\/label>\r\n <div class=\"file-upload-area\">\r\n <div class=\"file-upload-text\">\r\n <strong>Klik untuk upload rekam medis<\/strong><br>\r\n Format: JPG, PNG, PDF (Maksimal 5MB)\r\n <\/div>\r\n <input type=\"file\" id=\"rekam_medis\" name=\"rekam_medis\" accept=\"image\/jpeg,image\/jpg,image\/png,application\/pdf\" onchange=\"displayFileName(this, 'rm-display')\">\r\n <\/div>\r\n <div id=\"rm-display\" class=\"file-name-display\"><\/div>\r\n <p class=\"help-text\">Jika ada surat rujukan dokter atau hasil pemeriksaan sebelumnya<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <button type=\"submit\" class=\"btn-submit\" id=\"submit-btn\">\r\n Kirim Pendaftaran\r\n <\/button>\r\n\r\n <p style=\"text-align:center;margin-top:20px;color:#666;font-size:0.9em;\">\r\n Dengan mendaftar, Anda menyetujui bahwa data yang diberikan adalah benar dan dapat dipertanggungjawabkan.\r\n <\/p>\r\n <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"modal-overlay\" id=\"modal-overlay\"><\/div>\r\n\r\n \r\n <div class=\"modal\" id=\"success-modal\">\r\n <div class=\"modal-header\">\r\n <h2>Pendaftaran Berhasil!<\/h2>\r\n <\/div>\r\n <div class=\"modal-body\">\r\n <p class=\"modal-message\" id=\"success-message\">Pendaftaran berhasil! Tim kami akan menghubungi Anda segera.<\/p>\r\n <button class=\"modal-btn\" onclick=\"closeModal()\">OK, Mengerti<\/button>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"modal modal-error\" id=\"error-modal\">\r\n <div class=\"modal-header\">\r\n <h2>Terjadi Kesalahan<\/h2>\r\n <\/div>\r\n <div class=\"modal-body\">\r\n <p class=\"modal-message\" id=\"error-message\">Terjadi kesalahan. Silakan coba lagi.<\/p>\r\n <button class=\"modal-btn\" onclick=\"closeModal()\">Coba Lagi<\/button>\r\n <\/div>\r\n <\/div>\r\n\r\n <script>\r\n \/\/ Global variable to store nonce\r\n let bingxueNonce = null;\r\n\r\n \/\/ Fetch nonce on page load\r\n document.addEventListener('DOMContentLoaded', function() {\r\n fetch('https:\/\/bingxueindonesia.co.id\/wp-admin\/admin-ajax.php?action=bingxue_sumbing_get_nonce')\r\n .then(response => response.json())\r\n .then(data => {\r\n if (data.success && data.data.nonce) {\r\n bingxueNonce = data.data.nonce;\r\n console.log('Security token loaded');\r\n }\r\n })\r\n .catch(error => {\r\n console.error('Failed to load security token:', error);\r\n });\r\n });\r\n\r\n function displayFileName(input, displayId) {\r\n const display = document.getElementById(displayId);\r\n if (input.files && input.files[0]) {\r\n const fileSize = (input.files[0].size \/ 1024 \/ 1024).toFixed(2); \/\/ MB\r\n if (fileSize > 5) {\r\n alert('Ukuran file maksimal 5MB!');\r\n input.value = '';\r\n display.style.display = 'none';\r\n return;\r\n }\r\n display.textContent = '\u2713 ' + input.files[0].name + ' (' + fileSize + ' MB)';\r\n display.style.display = 'block';\r\n } else {\r\n display.style.display = 'none';\r\n }\r\n }\r\n\r\n function showModal(type, message) {\r\n const overlay = document.getElementById('modal-overlay');\r\n const modal = document.getElementById(type + '-modal');\r\n const messageEl = document.getElementById(type + '-message');\r\n \r\n \/\/ Translate field names to Indonesian\r\n const fieldTranslations = {\r\n 'nama_anak': 'Nama Anak',\r\n 'umur_anak': 'Umur Anak',\r\n 'nama_orangtua': 'Nama Orang Tua\/Wali',\r\n 'nomor_hp': 'Nomor HP\/WhatsApp',\r\n 'alamat': 'Alamat Lengkap',\r\n 'jenis_sumbing': 'Jenis Sumbing',\r\n 'berat_badan': 'Berat Badan',\r\n 'foto_sumbing': 'Foto Bibir\/Langit-Langit',\r\n 'rekam_medis': 'Rekam Medis'\r\n };\r\n \r\n \/\/ Replace field names in error message\r\n let displayMessage = message;\r\n Object.keys(fieldTranslations).forEach(field => {\r\n const regex = new RegExp(field, 'gi');\r\n displayMessage = displayMessage.replace(regex, fieldTranslations[field]);\r\n });\r\n \r\n messageEl.textContent = displayMessage;\r\n overlay.style.display = 'block';\r\n modal.style.display = 'block';\r\n \r\n \/\/ Prevent body scroll\r\n document.body.style.overflow = 'hidden';\r\n }\r\n\r\n function closeModal() {\r\n const overlay = document.getElementById('modal-overlay');\r\n const successModal = document.getElementById('success-modal');\r\n const errorModal = document.getElementById('error-modal');\r\n \r\n overlay.style.display = 'none';\r\n successModal.style.display = 'none';\r\n errorModal.style.display = 'none';\r\n \r\n \/\/ Restore body scroll\r\n document.body.style.overflow = 'auto';\r\n }\r\n\r\n \/\/ Close modal on overlay click\r\n document.getElementById('modal-overlay').addEventListener('click', closeModal);\r\n\r\n document.getElementById('bingxue-form').addEventListener('submit', function(e) {\r\n e.preventDefault();\r\n \r\n \/\/ Check if nonce is loaded\r\n if (!bingxueNonce) {\r\n showModal('error', 'Sedang memuat form... Silakan coba lagi dalam beberapa detik.');\r\n return;\r\n }\r\n \r\n const form = this;\r\n const formData = new FormData(form);\r\n const submitBtn = document.getElementById('submit-btn');\r\n const loading = document.getElementById('loading');\r\n \r\n \/\/ Show loading\r\n loading.style.display = 'block';\r\n submitBtn.disabled = true;\r\n \r\n \/\/ Add nonce and action\r\n formData.append('action', 'bingxue_sumbing_submit_form');\r\n formData.append('nonce', bingxueNonce);\r\n\r\n \/\/ Submit via AJAX\r\n fetch('\/wp-admin\/admin-ajax.php', {\r\n method: 'POST',\r\n body: formData\r\n })\r\n .then(response => response.json())\r\n .then(data => {\r\n loading.style.display = 'none';\r\n submitBtn.disabled = false;\r\n \r\n if (data.success) {\r\n \/\/ Show success modal\r\n showModal('success', data.data);\r\n \r\n \/\/ Reset form\r\n form.reset();\r\n document.getElementById('foto-display').style.display = 'none';\r\n document.getElementById('rm-display').style.display = 'none';\r\n \r\n \/\/ Refresh nonce\r\n fetch('https:\/\/bingxueindonesia.co.id\/wp-admin\/admin-ajax.php?action=bingxue_sumbing_get_nonce')\r\n .then(response => response.json())\r\n .then(data => {\r\n if (data.success && data.data.nonce) {\r\n bingxueNonce = data.data.nonce;\r\n }\r\n });\r\n } else {\r\n \/\/ Show error modal\r\n showModal('error', data.data);\r\n }\r\n })\r\n .catch(error => {\r\n loading.style.display = 'none';\r\n submitBtn.disabled = false;\r\n showModal('error', 'Terjadi kesalahan. Silakan coba lagi.');\r\n console.error('Error:', error);\r\n });\r\n });\r\n <\/script>\r\n<\/body>\r\n<\/html>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Form Pendaftaran – Bingxue Smile Project Form Pendaftaran Bingxue Smile Project – Operasi Bibir Sumbing Gratis Mengirim data pendaftaran… Data Anak (Pasien) Nama Lengkap Anak * Umur Anak (tahun) * Berat Badan Anak (kg) * Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit Data Orang Tua \/ Wali Nama Orang Tua\/Wali * Nomor HP\/WhatsApp […]<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-6292","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n<title>Form Pendaftaran - Bingxue<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Form Pendaftaran - Bingxue\" \/>\n<meta property=\"og:description\" content=\"Form Pendaftaran – Bingxue Smile Project Form Pendaftaran Bingxue Smile Project – Operasi Bibir Sumbing Gratis Mengirim data pendaftaran… Data Anak (Pasien) Nama Lengkap Anak * Umur Anak (tahun) * Berat Badan Anak (kg) * Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit Data Orang Tua \/ Wali Nama Orang Tua\/Wali * Nomor HP\/WhatsApp […]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/\" \/>\n<meta property=\"og:site_name\" content=\"Bingxue\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bingxueindonesia\/\" \/>\n<meta property=\"article:modified_time\" content=\"2026-04-16T03:51:04+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/\",\"url\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/\",\"name\":\"Form Pendaftaran - Bingxue\",\"isPartOf\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/#website\"},\"datePublished\":\"2026-02-27T07:28:34+00:00\",\"dateModified\":\"2026-04-16T03:51:04+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/bingxueindonesia.co.id\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Form Pendaftaran\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/#website\",\"url\":\"https:\/\/bingxueindonesia.co.id\/\",\"name\":\"Bingxue\",\"description\":\"\",\"publisher\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/bingxueindonesia.co.id\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/#organization\",\"name\":\"Bingxue\",\"url\":\"https:\/\/bingxueindonesia.co.id\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/\",\"url\":\"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png\",\"contentUrl\":\"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png\",\"width\":211,\"height\":63,\"caption\":\"Bingxue\"},\"image\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/\"},\"sameAs\":[\"https:\/\/www.facebook.com\/bingxueindonesia\/\",\"https:\/\/www.instagram.com\/bingxue.indonesia\/\"]}]}<\/script>\n","yoast_head_json":{"title":"Form Pendaftaran - Bingxue","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/","og_locale":"en_US","og_type":"article","og_title":"Form Pendaftaran - Bingxue","og_description":"Form Pendaftaran – Bingxue Smile Project Form Pendaftaran Bingxue Smile Project – Operasi Bibir Sumbing Gratis Mengirim data pendaftaran… Data Anak (Pasien) Nama Lengkap Anak * Umur Anak (tahun) * Berat Badan Anak (kg) * Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit Data Orang Tua \/ Wali Nama Orang Tua\/Wali * Nomor HP\/WhatsApp […]","og_url":"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/","og_site_name":"Bingxue","article_publisher":"https:\/\/www.facebook.com\/bingxueindonesia\/","article_modified_time":"2026-04-16T03:51:04+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/","url":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/","name":"Form Pendaftaran - Bingxue","isPartOf":{"@id":"https:\/\/bingxueindonesia.co.id\/#website"},"datePublished":"2026-02-27T07:28:34+00:00","dateModified":"2026-04-16T03:51:04+00:00","breadcrumb":{"@id":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/bingxueindonesia.co.id\/"},{"@type":"ListItem","position":2,"name":"Form Pendaftaran"}]},{"@type":"WebSite","@id":"https:\/\/bingxueindonesia.co.id\/#website","url":"https:\/\/bingxueindonesia.co.id\/","name":"Bingxue","description":"","publisher":{"@id":"https:\/\/bingxueindonesia.co.id\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/bingxueindonesia.co.id\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/bingxueindonesia.co.id\/#organization","name":"Bingxue","url":"https:\/\/bingxueindonesia.co.id\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/","url":"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png","contentUrl":"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png","width":211,"height":63,"caption":"Bingxue"},"image":{"@id":"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/bingxueindonesia\/","https:\/\/www.instagram.com\/bingxue.indonesia\/"]}]}},"jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages\/6292","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/comments?post=6292"}],"version-history":[{"count":22,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages\/6292\/revisions"}],"predecessor-version":[{"id":7111,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages\/6292\/revisions\/7111"}],"wp:attachment":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/media?parent=6292"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}

\n\t\t\t\t

\n\t\t\t\t\t

\n\t\t\t\t

\n\t\t\t\t\t\r\n\r\n\r\n \r\n \r\n Form Pendaftaran - Bingxue Smile Project<\/title>\r\n <link href=\"https:\/\/fonts.googleapis.com\/css2?family=Poppins:wght@300;400;500;600;700&display=swap\" rel=\"stylesheet\">\r\n <style>\r\n * {\r\n margin: 0;\r\n padding: 0;\r\n box-sizing: border-box;\r\n }\r\n\r\n body {\r\n font-family: 'Poppins', sans-serif;\r\n line-height: 1.6;\r\n color: #333;\r\n background: #f8f9fa;\r\n }\r\n\r\n .container {\r\n max-width: 800px;\r\n margin: 0 auto;\r\n padding: 20px;\r\n }\r\n\r\n .form-header {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 40px 30px;\r\n border-radius: 15px 15px 0 0;\r\n text-align: center;\r\n }\r\n\r\n .form-header h1 {\r\n font-size: 2em;\r\n margin-bottom: 10px;\r\n font-weight: 700;\r\n }\r\n\r\n .form-header p {\r\n font-size: 1em;\r\n opacity: 0.95;\r\n font-weight: 400;\r\n }\r\n\r\n .form-container {\r\n background: white;\r\n padding: 40px;\r\n border-radius: 0 0 15px 15px;\r\n box-shadow: 0 4px 15px rgba(0,0,0,0.1);\r\n }\r\n\r\n .form-section {\r\n margin-bottom: 35px;\r\n }\r\n\r\n .section-title {\r\n font-size: 1.3em;\r\n font-weight: 600;\r\n color: #f0832c;\r\n margin-bottom: 20px;\r\n padding-bottom: 10px;\r\n border-bottom: 2px solid #f0832c;\r\n }\r\n\r\n .form-group {\r\n margin-bottom: 20px;\r\n }\r\n\r\n .form-group label {\r\n display: block;\r\n font-weight: 500;\r\n margin-bottom: 8px;\r\n color: #333;\r\n font-size: 0.95em;\r\n }\r\n\r\n .required {\r\n color: #d63638;\r\n font-weight: 700;\r\n }\r\n\r\n .form-group input[type=\"text\"],\r\n .form-group input[type=\"number\"],\r\n .form-group select,\r\n .form-group textarea {\r\n width: 100%;\r\n padding: 12px 15px;\r\n border: 2px solid #e0e0e0;\r\n border-radius: 8px;\r\n font-size: 1em;\r\n font-family: 'Poppins', sans-serif;\r\n transition: border-color 0.3s;\r\n }\r\n\r\n .form-group input:focus,\r\n .form-group select:focus,\r\n .form-group textarea:focus {\r\n outline: none;\r\n border-color: #f0832c;\r\n }\r\n\r\n .form-group textarea {\r\n resize: vertical;\r\n min-height: 100px;\r\n }\r\n\r\n .form-row {\r\n display: grid;\r\n grid-template-columns: 1fr 1fr;\r\n gap: 20px;\r\n }\r\n\r\n .file-upload-area {\r\n border: 2px dashed #f0832c;\r\n padding: 30px;\r\n text-align: center;\r\n border-radius: 8px;\r\n cursor: pointer;\r\n transition: background-color 0.3s;\r\n position: relative;\r\n }\r\n\r\n .file-upload-area:hover {\r\n background-color: #fff5ef;\r\n }\r\n\r\n .file-upload-area input[type=\"file\"] {\r\n position: absolute;\r\n width: 100%;\r\n height: 100%;\r\n top: 0;\r\n left: 0;\r\n opacity: 0;\r\n cursor: pointer;\r\n }\r\n\r\n .file-upload-icon {\r\n font-size: 2.5em;\r\n color: #f0832c;\r\n margin-bottom: 10px;\r\n }\r\n\r\n .file-upload-text {\r\n color: #666;\r\n font-size: 0.95em;\r\n }\r\n\r\n .file-name-display {\r\n margin-top: 10px;\r\n padding: 10px;\r\n background: #e3f2fd;\r\n border-radius: 5px;\r\n color: #1976d2;\r\n font-weight: 500;\r\n display: none;\r\n }\r\n\r\n .help-text {\r\n font-size: 0.85em;\r\n color: #666;\r\n margin-top: 5px;\r\n font-style: italic;\r\n }\r\n\r\n .btn-submit {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 15px 50px;\r\n border: none;\r\n border-radius: 50px;\r\n font-size: 1.1em;\r\n font-weight: 600;\r\n font-family: 'Poppins', sans-serif;\r\n cursor: pointer;\r\n width: 100%;\r\n transition: all 0.3s;\r\n box-shadow: 0 4px 15px rgba(240, 131, 44, 0.3);\r\n }\r\n\r\n .btn-submit:hover {\r\n transform: translateY(-2px);\r\n box-shadow: 0 6px 20px rgba(240, 131, 44, 0.4);\r\n }\r\n\r\n .btn-submit:disabled {\r\n opacity: 0.6;\r\n cursor: not-allowed;\r\n transform: none;\r\n }\r\n\r\n .loading {\r\n display: none;\r\n text-align: center;\r\n padding: 20px;\r\n }\r\n\r\n .loading-spinner {\r\n border: 3px solid #f3f3f3;\r\n border-top: 3px solid #f0832c;\r\n border-radius: 50%;\r\n width: 40px;\r\n height: 40px;\r\n animation: spin 1s linear infinite;\r\n margin: 0 auto 10px;\r\n }\r\n\r\n @keyframes spin {\r\n 0% { transform: rotate(0deg); }\r\n 100% { transform: rotate(360deg); }\r\n }\r\n\r\n \/* Modal Popup Styles *\/\r\n .modal-overlay {\r\n display: none;\r\n position: fixed;\r\n top: 0;\r\n left: 0;\r\n width: 100%;\r\n height: 100%;\r\n background: rgba(0, 0, 0, 0.6);\r\n z-index: 9998;\r\n animation: fadeIn 0.3s;\r\n }\r\n\r\n .modal {\r\n display: none;\r\n position: fixed;\r\n top: 50%;\r\n left: 50%;\r\n transform: translate(-50%, -50%);\r\n background: white;\r\n border-radius: 12px;\r\n box-shadow: 0 10px 40px rgba(0,0,0,0.3);\r\n z-index: 9999;\r\n width: 350px !important;\r\n max-width: 90% !important;\r\n animation: slideIn 0.3s;\r\n overflow: hidden;\r\n }\r\n\r\n @keyframes fadeIn {\r\n from { opacity: 0; }\r\n to { opacity: 1; }\r\n }\r\n\r\n @keyframes slideIn {\r\n from {\r\n opacity: 0;\r\n transform: translate(-50%, -60%);\r\n }\r\n to {\r\n opacity: 1;\r\n transform: translate(-50%, -50%);\r\n }\r\n }\r\n\r\n .modal-header {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 15px !important;\r\n text-align: center;\r\n display: flex !important;\r\n align-items: center !important;\r\n justify-content: center !important;\r\n }\r\n\r\n .modal-icon {\r\n font-size: 2em;\r\n margin-bottom: 5px;\r\n display: block;\r\n }\r\n\r\n .modal-header h2 {\r\n font-size: 1em;\r\n font-weight: 700;\r\n margin: 0;\r\n font-family: 'Poppins', sans-serif;\r\n text-align: center !important;\r\n width: 100% !important;\r\n }\r\n\r\n .modal-body {\r\n padding: 20px 15px !important;\r\n text-align: center;\r\n }\r\n\r\n .modal-message {\r\n font-size: 0.9em;\r\n color: #333;\r\n line-height: 1.4;\r\n margin-bottom: 15px;\r\n font-weight: 400;\r\n font-family: 'Poppins', sans-serif;\r\n }\r\n\r\n .modal-btn {\r\n background: linear-gradient(135deg, #f0832c 0%, #e06010 100%);\r\n color: white;\r\n padding: 10px 30px;\r\n border: none;\r\n border-radius: 8px;\r\n font-size: 0.9em;\r\n font-weight: 600;\r\n font-family: 'Poppins', sans-serif;\r\n cursor: pointer;\r\n transition: all 0.3s;\r\n box-shadow: 0 3px 10px rgba(240, 131, 44, 0.3);\r\n }\r\n\r\n .modal-btn:hover {\r\n transform: translateY(-2px);\r\n box-shadow: 0 6px 20px rgba(240, 131, 44, 0.4);\r\n }\r\n\r\n .modal-error .modal-header {\r\n background: linear-gradient(135deg, #dc3545 0%, #c82333 100%);\r\n }\r\n\r\n .modal-error .modal-btn {\r\n background: linear-gradient(135deg, #dc3545 0%, #c82333 100%);\r\n box-shadow: 0 4px 15px rgba(220, 53, 69, 0.3);\r\n }\r\n\r\n .modal-error .modal-btn:hover {\r\n box-shadow: 0 6px 20px rgba(220, 53, 69, 0.4);\r\n }\r\n\r\n @media (max-width: 768px) {\r\n .form-header h1 {\r\n font-size: 1.5em;\r\n }\r\n\r\n .form-container {\r\n padding: 25px;\r\n }\r\n\r\n .form-row {\r\n grid-template-columns: 1fr;\r\n }\r\n\r\n .modal {\r\n max-width: 90%;\r\n }\r\n\r\n .modal-header h2 {\r\n font-size: 1.3em;\r\n }\r\n\r\n .modal-icon {\r\n font-size: 2.5em;\r\n }\r\n\r\n .modal-message {\r\n font-size: 0.95em;\r\n }\r\n }\r\n <\/style>\r\n<\/head>\r\n<body>\r\n <div class=\"container\">\r\n <div class=\"form-header\">\r\n <h1>Form Pendaftaran<\/h1>\r\n <p>Bingxue Smile Project - Operasi Bibir Sumbing Gratis<\/p>\r\n <\/div>\r\n\r\n <div class=\"form-container\">\r\n \r\n <div id=\"loading\" class=\"loading\">\r\n <div class=\"loading-spinner\"><\/div>\r\n <p>Mengirim data pendaftaran...<\/p>\r\n <\/div>\r\n\r\n <form id=\"bingxue-form\" enctype=\"multipart\/form-data\" action=\"\">\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Data Anak (Pasien)<\/h2>\r\n \r\n <div class=\"form-row\">\r\n <div class=\"form-group\">\r\n <label>Nama Lengkap Anak <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" name=\"nama_anak\" required placeholder=\"Nama lengkap sesuai akta kelahiran\">\r\n <\/div>\r\n <div class=\"form-group\">\r\n <label>Umur Anak (tahun) <span class=\"required\">*<\/span><\/label>\r\n <input type=\"number\" name=\"umur_anak\" required min=\"0\" max=\"18\" placeholder=\"Contoh: 2\">\r\n <\/div>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Berat Badan Anak (kg) <span class=\"required\">*<\/span><\/label>\r\n <input type=\"number\" name=\"berat_badan\" required step=\"0.1\" min=\"0\" max=\"100\" placeholder=\"Contoh: 5.5\">\r\n <p class=\"help-text\">Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Data Orang Tua \/ Wali<\/h2>\r\n \r\n <div class=\"form-group\">\r\n <label>Nama Orang Tua\/Wali <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" name=\"nama_orangtua\" required placeholder=\"Nama ayah\/ibu\/wali\">\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Nomor HP\/WhatsApp <span class=\"required\">*<\/span><\/label>\r\n <input type=\"text\" name=\"nomor_hp\" required placeholder=\"08xx xxxx xxxx\">\r\n <p class=\"help-text\">Pastikan nomor aktif untuk dihubungi tim kami<\/p>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Alamat Lengkap <span class=\"required\">*<\/span><\/label>\r\n <textarea name=\"alamat\" required placeholder=\"Jalan, RT\/RW, Kelurahan, Kecamatan, Kota\/Kabupaten, Provinsi, Kode Pos\"><\/textarea>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Kondisi Medis<\/h2>\r\n \r\n <div class=\"form-group\">\r\n <label>Jenis Sumbing <span class=\"required\">*<\/span><\/label>\r\n <select name=\"jenis_sumbing\" required>\r\n <option value=\"\">-- Pilih Jenis Sumbing --<\/option>\r\n <option value=\"Bibir Sumbing Saja\">Bibir Sumbing Saja<\/option>\r\n <option value=\"Celah Langit-Langit Saja\">Celah Langit-Langit Saja<\/option>\r\n <option value=\"Bibir Sumbing dan Celah Langit-Langit\">Bibir Sumbing dan Celah Langit-Langit<\/option>\r\n <\/select>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"form-section\">\r\n <h2 class=\"section-title\">Upload Dokumen<\/h2>\r\n \r\n <div class=\"form-group\">\r\n <label>Foto Bibir\/Langit-Langit Anak <span class=\"required\">*<\/span><\/label>\r\n <div class=\"file-upload-area\">\r\n <div class=\"file-upload-text\">\r\n <strong>Klik untuk upload foto<\/strong><br>\r\n Format: JPG, PNG (Maksimal 5MB)\r\n <\/div>\r\n <input type=\"file\" id=\"foto_sumbing\" name=\"foto_sumbing\" accept=\"image\/jpeg,image\/jpg,image\/png\" required onchange=\"displayFileName(this, 'foto-display')\">\r\n <\/div>\r\n <div id=\"foto-display\" class=\"file-name-display\"><\/div>\r\n <p class=\"help-text\">Upload foto tampak depan dengan kepala mengadah ke atas dan mulut terbuka<\/p>\r\n <\/div>\r\n\r\n <div class=\"form-group\">\r\n <label>Rekam Medis (Opsional)<\/label>\r\n <div class=\"file-upload-area\">\r\n <div class=\"file-upload-text\">\r\n <strong>Klik untuk upload rekam medis<\/strong><br>\r\n Format: JPG, PNG, PDF (Maksimal 5MB)\r\n <\/div>\r\n <input type=\"file\" id=\"rekam_medis\" name=\"rekam_medis\" accept=\"image\/jpeg,image\/jpg,image\/png,application\/pdf\" onchange=\"displayFileName(this, 'rm-display')\">\r\n <\/div>\r\n <div id=\"rm-display\" class=\"file-name-display\"><\/div>\r\n <p class=\"help-text\">Jika ada surat rujukan dokter atau hasil pemeriksaan sebelumnya<\/p>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <button type=\"submit\" class=\"btn-submit\" id=\"submit-btn\">\r\n Kirim Pendaftaran\r\n <\/button>\r\n\r\n <p style=\"text-align:center;margin-top:20px;color:#666;font-size:0.9em;\">\r\n Dengan mendaftar, Anda menyetujui bahwa data yang diberikan adalah benar dan dapat dipertanggungjawabkan.\r\n <\/p>\r\n <input type=\"hidden\" name=\"trp-form-language\" value=\"en\"\/><\/form>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"modal-overlay\" id=\"modal-overlay\"><\/div>\r\n\r\n \r\n <div class=\"modal\" id=\"success-modal\">\r\n <div class=\"modal-header\">\r\n <h2>Pendaftaran Berhasil!<\/h2>\r\n <\/div>\r\n <div class=\"modal-body\">\r\n <p class=\"modal-message\" id=\"success-message\">Pendaftaran berhasil! Tim kami akan menghubungi Anda segera.<\/p>\r\n <button class=\"modal-btn\" onclick=\"closeModal()\">OK, Mengerti<\/button>\r\n <\/div>\r\n <\/div>\r\n\r\n \r\n <div class=\"modal modal-error\" id=\"error-modal\">\r\n <div class=\"modal-header\">\r\n <h2>Terjadi Kesalahan<\/h2>\r\n <\/div>\r\n <div class=\"modal-body\">\r\n <p class=\"modal-message\" id=\"error-message\">Terjadi kesalahan. Silakan coba lagi.<\/p>\r\n <button class=\"modal-btn\" onclick=\"closeModal()\">Coba Lagi<\/button>\r\n <\/div>\r\n <\/div>\r\n\r\n <script>\r\n \/\/ Global variable to store nonce\r\n let bingxueNonce = null;\r\n\r\n \/\/ Fetch nonce on page load\r\n document.addEventListener('DOMContentLoaded', function() {\r\n fetch('https:\/\/bingxueindonesia.co.id\/wp-admin\/admin-ajax.php?action=bingxue_sumbing_get_nonce')\r\n .then(response => response.json())\r\n .then(data => {\r\n if (data.success && data.data.nonce) {\r\n bingxueNonce = data.data.nonce;\r\n console.log('Security token loaded');\r\n }\r\n })\r\n .catch(error => {\r\n console.error('Failed to load security token:', error);\r\n });\r\n });\r\n\r\n function displayFileName(input, displayId) {\r\n const display = document.getElementById(displayId);\r\n if (input.files && input.files[0]) {\r\n const fileSize = (input.files[0].size \/ 1024 \/ 1024).toFixed(2); \/\/ MB\r\n if (fileSize > 5) {\r\n alert('Ukuran file maksimal 5MB!');\r\n input.value = '';\r\n display.style.display = 'none';\r\n return;\r\n }\r\n display.textContent = '\u2713 ' + input.files[0].name + ' (' + fileSize + ' MB)';\r\n display.style.display = 'block';\r\n } else {\r\n display.style.display = 'none';\r\n }\r\n }\r\n\r\n function showModal(type, message) {\r\n const overlay = document.getElementById('modal-overlay');\r\n const modal = document.getElementById(type + '-modal');\r\n const messageEl = document.getElementById(type + '-message');\r\n \r\n \/\/ Translate field names to Indonesian\r\n const fieldTranslations = {\r\n 'nama_anak': 'Nama Anak',\r\n 'umur_anak': 'Umur Anak',\r\n 'nama_orangtua': 'Nama Orang Tua\/Wali',\r\n 'nomor_hp': 'Nomor HP\/WhatsApp',\r\n 'alamat': 'Alamat Lengkap',\r\n 'jenis_sumbing': 'Jenis Sumbing',\r\n 'berat_badan': 'Berat Badan',\r\n 'foto_sumbing': 'Foto Bibir\/Langit-Langit',\r\n 'rekam_medis': 'Rekam Medis'\r\n };\r\n \r\n \/\/ Replace field names in error message\r\n let displayMessage = message;\r\n Object.keys(fieldTranslations).forEach(field => {\r\n const regex = new RegExp(field, 'gi');\r\n displayMessage = displayMessage.replace(regex, fieldTranslations[field]);\r\n });\r\n \r\n messageEl.textContent = displayMessage;\r\n overlay.style.display = 'block';\r\n modal.style.display = 'block';\r\n \r\n \/\/ Prevent body scroll\r\n document.body.style.overflow = 'hidden';\r\n }\r\n\r\n function closeModal() {\r\n const overlay = document.getElementById('modal-overlay');\r\n const successModal = document.getElementById('success-modal');\r\n const errorModal = document.getElementById('error-modal');\r\n \r\n overlay.style.display = 'none';\r\n successModal.style.display = 'none';\r\n errorModal.style.display = 'none';\r\n \r\n \/\/ Restore body scroll\r\n document.body.style.overflow = 'auto';\r\n }\r\n\r\n \/\/ Close modal on overlay click\r\n document.getElementById('modal-overlay').addEventListener('click', closeModal);\r\n\r\n document.getElementById('bingxue-form').addEventListener('submit', function(e) {\r\n e.preventDefault();\r\n \r\n \/\/ Check if nonce is loaded\r\n if (!bingxueNonce) {\r\n showModal('error', 'Sedang memuat form... Silakan coba lagi dalam beberapa detik.');\r\n return;\r\n }\r\n \r\n const form = this;\r\n const formData = new FormData(form);\r\n const submitBtn = document.getElementById('submit-btn');\r\n const loading = document.getElementById('loading');\r\n \r\n \/\/ Show loading\r\n loading.style.display = 'block';\r\n submitBtn.disabled = true;\r\n \r\n \/\/ Add nonce and action\r\n formData.append('action', 'bingxue_sumbing_submit_form');\r\n formData.append('nonce', bingxueNonce);\r\n\r\n \/\/ Submit via AJAX\r\n fetch('\/wp-admin\/admin-ajax.php', {\r\n method: 'POST',\r\n body: formData\r\n })\r\n .then(response => response.json())\r\n .then(data => {\r\n loading.style.display = 'none';\r\n submitBtn.disabled = false;\r\n \r\n if (data.success) {\r\n \/\/ Show success modal\r\n showModal('success', data.data);\r\n \r\n \/\/ Reset form\r\n form.reset();\r\n document.getElementById('foto-display').style.display = 'none';\r\n document.getElementById('rm-display').style.display = 'none';\r\n \r\n \/\/ Refresh nonce\r\n fetch('https:\/\/bingxueindonesia.co.id\/wp-admin\/admin-ajax.php?action=bingxue_sumbing_get_nonce')\r\n .then(response => response.json())\r\n .then(data => {\r\n if (data.success && data.data.nonce) {\r\n bingxueNonce = data.data.nonce;\r\n }\r\n });\r\n } else {\r\n \/\/ Show error modal\r\n showModal('error', data.data);\r\n }\r\n })\r\n .catch(error => {\r\n loading.style.display = 'none';\r\n submitBtn.disabled = false;\r\n showModal('error', 'Terjadi kesalahan. Silakan coba lagi.');\r\n console.error('Error:', error);\r\n });\r\n });\r\n <\/script>\r\n<\/body>\r\n<\/html>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>","protected":false},"excerpt":{"rendered":"<p>Form Pendaftaran – Bingxue Smile Project Form Pendaftaran Bingxue Smile Project – Operasi Bibir Sumbing Gratis Mengirim data pendaftaran… Data Anak (Pasien) Nama Lengkap Anak * Umur Anak (tahun) * Berat Badan Anak (kg) * Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit Data Orang Tua \/ Wali Nama Orang Tua\/Wali * Nomor HP\/WhatsApp […]<\/p>","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-6292","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n<title>Form Pendaftaran - Bingxue<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Form Pendaftaran - Bingxue\" \/>\n<meta property=\"og:description\" content=\"Form Pendaftaran – Bingxue Smile Project Form Pendaftaran Bingxue Smile Project – Operasi Bibir Sumbing Gratis Mengirim data pendaftaran… Data Anak (Pasien) Nama Lengkap Anak * Umur Anak (tahun) * Berat Badan Anak (kg) * Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit Data Orang Tua \/ Wali Nama Orang Tua\/Wali * Nomor HP\/WhatsApp […]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/\" \/>\n<meta property=\"og:site_name\" content=\"Bingxue\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/bingxueindonesia\/\" \/>\n<meta property=\"article:modified_time\" content=\"2026-04-16T03:51:04+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/\",\"url\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/\",\"name\":\"Form Pendaftaran - Bingxue\",\"isPartOf\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/#website\"},\"datePublished\":\"2026-02-27T07:28:34+00:00\",\"dateModified\":\"2026-04-16T03:51:04+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/bingxueindonesia.co.id\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Form Pendaftaran\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/#website\",\"url\":\"https:\/\/bingxueindonesia.co.id\/\",\"name\":\"Bingxue\",\"description\":\"\",\"publisher\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/bingxueindonesia.co.id\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/#organization\",\"name\":\"Bingxue\",\"url\":\"https:\/\/bingxueindonesia.co.id\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/\",\"url\":\"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png\",\"contentUrl\":\"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png\",\"width\":211,\"height\":63,\"caption\":\"Bingxue\"},\"image\":{\"@id\":\"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/\"},\"sameAs\":[\"https:\/\/www.facebook.com\/bingxueindonesia\/\",\"https:\/\/www.instagram.com\/bingxue.indonesia\/\"]}]}<\/script>\n","yoast_head_json":{"title":"Form Pendaftaran - Bingxue","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/","og_locale":"en_US","og_type":"article","og_title":"Form Pendaftaran - Bingxue","og_description":"Form Pendaftaran – Bingxue Smile Project Form Pendaftaran Bingxue Smile Project – Operasi Bibir Sumbing Gratis Mengirim data pendaftaran… Data Anak (Pasien) Nama Lengkap Anak * Umur Anak (tahun) * Berat Badan Anak (kg) * Minimal 5kg untuk bibir sumbing, 10kg untuk celah langit-langit Data Orang Tua \/ Wali Nama Orang Tua\/Wali * Nomor HP\/WhatsApp […]","og_url":"https:\/\/bingxueindonesia.co.id\/en\/pendaftaran-sumbing\/","og_site_name":"Bingxue","article_publisher":"https:\/\/www.facebook.com\/bingxueindonesia\/","article_modified_time":"2026-04-16T03:51:04+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/","url":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/","name":"Form Pendaftaran - Bingxue","isPartOf":{"@id":"https:\/\/bingxueindonesia.co.id\/#website"},"datePublished":"2026-02-27T07:28:34+00:00","dateModified":"2026-04-16T03:51:04+00:00","breadcrumb":{"@id":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/bingxueindonesia.co.id\/pendaftaran-sumbing\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/bingxueindonesia.co.id\/"},{"@type":"ListItem","position":2,"name":"Form Pendaftaran"}]},{"@type":"WebSite","@id":"https:\/\/bingxueindonesia.co.id\/#website","url":"https:\/\/bingxueindonesia.co.id\/","name":"Bingxue","description":"","publisher":{"@id":"https:\/\/bingxueindonesia.co.id\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/bingxueindonesia.co.id\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/bingxueindonesia.co.id\/#organization","name":"Bingxue","url":"https:\/\/bingxueindonesia.co.id\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/","url":"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png","contentUrl":"https:\/\/bingxueindonesia.co.id\/wp-content\/uploads\/2024\/09\/image-40.png","width":211,"height":63,"caption":"Bingxue"},"image":{"@id":"https:\/\/bingxueindonesia.co.id\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/bingxueindonesia\/","https:\/\/www.instagram.com\/bingxue.indonesia\/"]}]}},"jetpack_sharing_enabled":true,"jetpack-related-posts":[],"_links":{"self":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages\/6292","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/comments?post=6292"}],"version-history":[{"count":22,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages\/6292\/revisions"}],"predecessor-version":[{"id":7111,"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/pages\/6292\/revisions\/7111"}],"wp:attachment":[{"href":"https:\/\/bingxueindonesia.co.id\/en\/wp-json\/wp\/v2\/media?parent=6292"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}