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2606:4700::6811:d6f3  Public Scan

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URL: https://share.hsforms.com/1ADoyQRNFS7qP5d5eoUldtg3eb89
Submission: On August 17 via manual from GB — Scanned from GB

Form analysis 1 forms found in the DOM

<form id="hs-form-003a3241-1345-4bba-8fe5-de5ea1495db6-96048962-e23f-4b37-b548-c3540e8ca826" class="hs-form-003a3241-1345-4bba-8fe5-de5ea1495db6 hs-form hs-form_theme-round" data-instance-id="96048962-e23f-4b37-b548-c3540e8ca826"
  data-form-id="003a3241-1345-4bba-8fe5-de5ea1495db6" data-portal-id="5706585" lang="en">
  <div class="hs-form__pagination-content-container">
    <div class="hs-form__row">
      <div class="hs-form__group">
        <div class="hs-form__field-row">
          <div class="hs-form__field-row__column">
            <div class="hs-form__field hs-form__field-firstname hs-firstname"><label id="firstname-label" for="firstname-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>First name</span></label><input
                id="firstname-input" class="hs-form__field__input" type="text" name="firstname" required="" autocomplete="given-name" inputmode="text" aria-invalid="false" aria-labelledby="firstname-label" aria-required="true" value=""></div>
          </div>
          <div class="hs-form__field-row__column">
            <div class="hs-form__field hs-form__field-lastname hs-lastname"><label id="lastname-label" for="lastname-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Last name</span></label><input
                id="lastname-input" class="hs-form__field__input" type="text" name="lastname" required="" autocomplete="family-name" inputmode="text" aria-invalid="false" aria-labelledby="lastname-label" aria-required="true" value=""></div>
          </div>
        </div>
      </div>
    </div>
    <div class="hs-form__row">
      <div class="hs-form__group">
        <div class="hs-form__field-row">
          <div class="hs-form__field-row__column">
            <div class="hs-form__field hs-form__field-email hs-email"><label id="email-label" for="email-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Email</span></label><input id="email-input"
                class="hs-form__field__input" type="email" name="email" required="" autocomplete="email" inputmode="email" aria-invalid="false" aria-labelledby="email-label" aria-required="true" value=""></div>
          </div>
          <div class="hs-form__field-row__column">
            <div class="hs-form__field hs-form__field-company hs-company"><label id="company-label" for="company-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Company name</span></label><input
                id="company-input" class="hs-form__field__input" type="text" name="company" required="" autocomplete="organization" inputmode="text" aria-invalid="false" aria-labelledby="company-label" aria-required="true" value=""></div>
          </div>
        </div>
      </div>
    </div>
    <div class="hs-form__row">
      <div class="hs-form__legal-consent">
        <div class="hs-form__legal-consent__row hs-form__legal-consent__row__communication-consent">
          <div class="hs-form__richtext">
            <p>Healthcare provider email address must be provided for form submission.</p>
          </div>
        </div>
        <div class="hs-form__legal-consent__row hs-form__legal-consent__row__communication-consent-checkbox">
          <div class="hs-form__field hs-form__field-LEGAL_CONSENT.subscription_type_7176295 hs-LEGAL_CONSENT.subscription_type_7176295"><label id="LEGAL_CONSENT.subscription_type_7176295-label-1"
              class="hs-form__field__label hs-form__field__checkbox__label hs-form__field__label--required"><input id="LEGAL_CONSENT.subscription_type_7176295-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox"
                name="LEGAL_CONSENT.subscription_type_7176295" required="" aria-invalid="false" aria-labelledby="LEGAL_CONSENT.subscription_type_7176295-label-1" aria-required="true" aria-checked="false" value="false"><span
                class="hs-form__field__checkbox__label-text">
                <p>I agree to receive other communications from Strata Decision Technology.</p>
              </span></label></div>
        </div>
        <div class="hs-form__legal-consent__row hs-form__legal-consent__row__privacy-policy">
          <div class="hs-form__richtext">
            <p>You can <a href="https://www.stratadecision.com/email-preferences/">unsubscribe</a> at any time. For more information about how we respect and protect your privacy, please review our
              <a href="https://www.stratadecision.com/privacypolicy/">Privacy Policy</a>.</p>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="hs-form__row">
    <div class="hs-form__actions"><button type="submit" name="Download Report" class="hs-form__actions__submit">Download Report</button></div>
  </div>
</form>

Text Content

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First name
Last name
Email
Company name

Healthcare provider email address must be provided for form submission.

I agree to receive other communications from Strata Decision Technology.

You can unsubscribe at any time. For more information about how we respect and
protect your privacy, please review our Privacy Policy.

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