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1 forms found in the DOM

POST https://jellyvision.activehosted.com/proc.php

<form method="POST" action="https://jellyvision.activehosted.com/proc.php" id="_form_65FDA2915CB06_" class="_form _form_30 _inline-form _dark ng-pristine ng-valid" novalidate="" data-styles-version="5">
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    <div class="_form_element _x68021535 _full_width ">
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        <div class="_row">
          <legend for="field[179][]" class="_form-label"> What preventive care services would you like to receive a reminder for? </legend>
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        <input data-autofill="false" type="hidden" id="field[179][]" name="field[179][]" value="~|" data-name="preventivecare24" autocomplete="off">
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          <input id="field_179Annual physical" type="checkbox" name="field[179][]" value="Annual physical" data-name="preventivecare24">
          <span><label for="field_179Annual physical">Annual physical</label></span>
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          <span><label for="field_179Dental">Dental</label></span>
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  <div class="_form-thank-you" style="display:none;"></div>
</form>

Text Content

Email*

What preventive care services would you like to receive a reminder for?
Annual physical
Vision
Dental
Mental health
Flu shot
Submit



ALEX

They say an apple a day keeps the doctor away, but that doesn’t mean you
shouldn’t go to the doctor. In fact, going to the doctor is best done routinely!

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