www.gazoi.com Open in urlscan Pro
54.166.116.146 Public Scan

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Submitted URL:
https://gazoi.com/home/A00912000020881621FAM
Effective URL:
https://www.gazoi.com/home/A00912000020881621FAM
Submission: On July 08 via api (July 8th 2022, 3:02:20 pm UTC) from US — Scanned from DE

Form analysis
4 forms found in the DOM

<form _ngcontent-fmo-c4="" autocomplete="off" class="needs-validation registration-form ng-untouched ng-dirty ng-invalid" enctype="multipart/form-data" novalidate="">
  <div _ngcontent-fmo-c4="" class="content fade active dstepper-block" id="test-l-1">
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="bs-stepper-header justify-content-center d-md-none">
        <div _ngcontent-fmo-c4="" class="step" data-target="#test-l-1"><button _ngcontent-fmo-c4="" class="step-trigger" aria-selected="false"><span _ngcontent-fmo-c4="" class="bs-stepper-circle">1</span><span _ngcontent-fmo-c4=""
              class="bs-stepper-label">Registration</span></button></div>
      </div>
    </div>
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-6 col-xl-5 form-group"></div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-8 col-lg-8">
          <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
            <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-6 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="inputPassword4">Salutation<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><select _ngcontent-fmo-c4=""
                class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="salutation" id="salutation" required="">
                <option _ngcontent-fmo-c4="" value="">Choose any one</option>
                <option _ngcontent-fmo-c4="" value="MR.">Mr.</option>
                <option _ngcontent-fmo-c4="" value="MRS.">Mrs.</option>
                <option _ngcontent-fmo-c4="" value="MS.">Ms.</option>
                <option _ngcontent-fmo-c4="" value="MISS">Miss</option>
                <option _ngcontent-fmo-c4="" value="DR.">Dr.</option>
                <option _ngcontent-fmo-c4="" value="PROF.">Prof.</option>
              </select><!----></div>
          </div>
          <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
            <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-6 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="first_name">First Name<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
                class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="firstName" id="first_name" placeholder="First Name" type="text" maxlength="99"><!----></div>
            <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-6 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="middle_name">Middle Name</label><input _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-valid"
                formcontrolname="middleName" id="middle_name" placeholder="Middle Name" type="text" maxlength="99"><!----></div>
            <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-6 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="last_name">Last Name<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
                class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="last_name" id="last_name" placeholder="Last Name" type="text" maxlength="99"><!----></div>
          </div>
        </div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-4 col-lg-4 d-flex justify-content-center align-items-start">
          <div _ngcontent-fmo-c4="" class="profile-img-upload custom-imp-col-flex">
            <div _ngcontent-fmo-c4="" class="avatar avatar-xxl"><img _ngcontent-fmo-c4="" alt="" class="rounded-circle bd" src="../../../assets/img/user.jpg"></div><input _ngcontent-fmo-c4="" accept="image/x-png,image/gif,image/jpeg" class="d-none"
              id="user-img-file-upload" name="image" ng2fileselect="" type="file"><button _ngcontent-fmo-c4="" class="btn btn-primary btn-s mt-2" onclick="$('#user-img-file-upload').click();" type="button"> Upload </button>
            <div _ngcontent-fmo-c4="" class="profile-warning-lebel"><label _ngcontent-fmo-c4="">Image size upto 2MB</label></div>
          </div>
        </div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="gender">Gender <span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><select _ngcontent-fmo-c4=""
            class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="gender" id="gender">
            <option _ngcontent-fmo-c4="" value="">Choose any one</option>
            <option _ngcontent-fmo-c4="" value="Male">Male</option>
            <option _ngcontent-fmo-c4="" value="Female">Female</option>
            <option _ngcontent-fmo-c4="" value="Other">Prefer not to answer</option>
          </select><!----></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group">
          <div _ngcontent-fmo-c4="" class="row no-gutters">
            <div _ngcontent-fmo-c4="" class="col-12 col-lg-12"><label _ngcontent-fmo-c4="" class="form-label" for="year">DOB<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label></div>
            <div _ngcontent-fmo-c4="" class="col-12 col-lg-4 pd-x-5-f"><ng-select _ngcontent-fmo-c4="" bindlabel="year" bindvalue="id" formcontrolname="year" id="year" placeholder="Year" role="listbox"
                class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid">
                <div class="ng-select-container">
                  <div class="ng-value-container">
                    <div class="ng-placeholder">Year</div><!----><!---->
                    <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="aff8dd0a293e" aria-expanded="false"></div>
                  </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
                </div><!---->
              </ng-select><!----></div>
            <div _ngcontent-fmo-c4="" class="col-12 col-lg-4 pd-x-5-f"><ng-select _ngcontent-fmo-c4="" bindlabel="month" bindvalue="id" formcontrolname="month" id="month" placeholder="Month" role="listbox"
                class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid">
                <div class="ng-select-container">
                  <div class="ng-value-container">
                    <div class="ng-placeholder">Month</div><!----><!---->
                    <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a963d2bff75d" aria-expanded="false"></div>
                  </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
                </div><!---->
              </ng-select><!----></div>
            <div _ngcontent-fmo-c4="" class="col-12 col-lg-4 pd-x-5-f"><ng-select _ngcontent-fmo-c4="" bindlabel="day" bindvalue="id" formcontrolname="day" id="day" placeholder="Day" role="listbox"
                class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid">
                <div class="ng-select-container">
                  <div class="ng-value-container">
                    <div class="ng-placeholder">Day</div><!----><!---->
                    <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a6fc1c43ed71" aria-expanded="false"></div>
                  </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
                </div><!---->
              </ng-select><!----></div>
          </div>
        </div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group userinfo">
          <div _ngcontent-fmo-c4="" class="row no-gutters">
            <div _ngcontent-fmo-c4="" class="col-12 col-lg-12"><label _ngcontent-fmo-c4="" class="form-label" for="year">Mobile<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label></div>
            <div _ngcontent-fmo-c4="" class="custom w-100"><ngx-intl-tel-input _ngcontent-fmo-c4="" formcontrolname="mobile" name="mobile" _nghost-fmo-c8="" class="ng-untouched ng-dirty ng-invalid">
                <div _ngcontent-fmo-c8="" class="intl-tel-input allow-dropdown separate-dial-code iti-sdc-2">
                  <div _ngcontent-fmo-c8="" class="flag-container" dropdown="">
                    <div _ngcontent-fmo-c8="" class="selected-flag dropdown-toggle" dropdowntoggle="" aria-haspopup="true">
                      <div _ngcontent-fmo-c8="" class="iti-flag us"></div><!---->
                      <div _ngcontent-fmo-c8="" class="selected-dial-code ng-star-inserted">+1</div>
                      <div _ngcontent-fmo-c8="" class="iti-arrow"></div>
                    </div><!---->
                  </div><input _ngcontent-fmo-c8="" autocomplete="off" type="tel" class="form-control custom-form-control ng-untouched ng-pristine ng-valid" id="phone" placeholder="201-555-0123" maxlength="15" validation="true">
                </div>
              </ngx-intl-tel-input><!----></div>
          </div>
        </div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="user_address">Address<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
            class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="address" id="address" placeholder="Address" type="text" maxlength="250"><!----></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="user_city">City<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
            class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="city" id="city" placeholder="City" type="text" maxlength="99"><!----></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="user_country">Country<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><ng-select _ngcontent-fmo-c4=""
            bindlabel="Name" bindvalue="RecId" formcontrolname="country_id" id="country_id" placeholder="Country" role="listbox" class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid">
            <div class="ng-select-container">
              <div class="ng-value-container">
                <div class="ng-placeholder">Country</div><!----><!---->
                <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a4ee1dd30922" aria-expanded="false"></div>
              </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
            </div><!---->
          </ng-select><!----><!----></div><!----><!---->
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group ng-star-inserted"><label _ngcontent-fmo-c4="" class="form-label" for="state_name">State/Province<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input
            _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="state_name" id="state_name" placeholder="State/Province" type="text" maxlength="60"><!----></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="zip_code">Zip Code/Pin Code<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
            class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="zip" id="zip" maxlength="10" placeholder="Zip Code/Pin Code" type="text"><!----></div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="registrationEmail">Email<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
            formcontrolname="RecId" id="RecId" type="hidden" value="0" class="ng-untouched ng-pristine ng-valid"><input _ngcontent-fmo-c4="" formcontrolname="portal_user_id" id="portal_user_id" type="hidden" value="0"
            class="ng-untouched ng-pristine ng-valid"><input _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="email_id" id="email_id" placeholder="Email" readonly="" required="" type="email"><!----></div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="password">Set Password<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4=""
            class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="password" id="password" placeholder="Password" type="password"><!----></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="confirm_password">Confirm Password<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input
            _ngcontent-fmo-c4="" autocomplete="new-password" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="confirm_password" id="confirm_password" placeholder="Confirm Password" type="password"><!----></div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10 mg-y-20">
        <div _ngcontent-fmo-c4="" class="form-group col-12 col-md-6 col-lg-4"><label _ngcontent-fmo-c4="" class="form-label" for="referral_code">Referred by (Referral code)</label><input _ngcontent-fmo-c4=""
            class="form-control ng-untouched ng-pristine ng-valid" formcontrolname="referred_by" id="referral_code" placeholder="Referral code" type="text" readonly=""></div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-12 mt-3 mt-lg-5 form-group text-center"><button _ngcontent-fmo-c4="" class="btn reg-form-submit-btn"> Next </button></div>
      </div>
    </div>
  </div>
</form>

<form _ngcontent-fmo-c4="" autocomplete="off" class="needs-validation registration-form ng-untouched ng-pristine ng-invalid" novalidate="">
  <div _ngcontent-fmo-c4="" class="content fade dstepper-none" id="test-l-2">
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="bs-stepper-header justify-content-center d-md-none">
        <div _ngcontent-fmo-c4="" class="step" data-target="#test-l-2"><button _ngcontent-fmo-c4="" class="step-trigger" aria-selected="false"><span _ngcontent-fmo-c4="" class="bs-stepper-circle">2</span><span _ngcontent-fmo-c4=""
              class="bs-stepper-label">Registration Type</span></button></div>
      </div>
    </div>
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10"><!---->
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group ng-star-inserted"><label _ngcontent-fmo-c4="" class="form-label" for="confirm_password">How did you hear about GaZoi?<span _ngcontent-fmo-c4=""
              class="tx-danger">*</span></label><select _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="heard_about_OSG" id="heard_about_OSG">
            <option _ngcontent-fmo-c4="" value="">Choose any one</option>
            <option _ngcontent-fmo-c4="" value="Blog">Blog</option>
            <option _ngcontent-fmo-c4="" value="Digital ad">Digital ad</option>
            <option _ngcontent-fmo-c4="" value="Direct Mail">Direct Mail</option>
            <option _ngcontent-fmo-c4="" value="Event &amp; Conference"> Event &amp; Conference </option>
            <option _ngcontent-fmo-c4="" value="Facebook">Facebook</option>
            <option _ngcontent-fmo-c4="" value="Flyer">Flyer</option>
            <option _ngcontent-fmo-c4="" value="Google Adwords">Google Adwords</option>
            <option _ngcontent-fmo-c4="" value="Google Search">Google Search</option>
            <option _ngcontent-fmo-c4="" value="LinkedIn">LinkedIn</option>
            <option _ngcontent-fmo-c4="" value="Newspaper ad">Newspaper ad</option>
            <option _ngcontent-fmo-c4="" value="Podcast">Podcast</option>
            <option _ngcontent-fmo-c4="" value="Referral from a healthcare professional"> Referral from a healthcare professional </option>
            <option _ngcontent-fmo-c4="" value="Support Group">Support Group</option>
            <option _ngcontent-fmo-c4="" value="Twitter">Twitter</option>
            <option _ngcontent-fmo-c4="" value="Other Social Media"> Other Social Media </option>
            <option _ngcontent-fmo-c4="" value="Other"> Other (Please Specify below box) </option>
          </select><!----></div><!---->
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="confirm_password">Registration Type<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><select
            _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="registrationType" id="registrationType">
            <option _ngcontent-fmo-c4="" value="">Choose any one</option>
            <option _ngcontent-fmo-c4="" value="NonHealthcareProfessional"> Non Healthcare Professional </option>
            <option _ngcontent-fmo-c4="" value="HealthcareProfessional"> Healthcare Professional </option>
          </select><!----></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-md-12 mt-3 mt-lg-5 form-group text-center"><button _ngcontent-fmo-c4="" class="btn reg-form-submit-btn mg-r-10"> Prev </button><button _ngcontent-fmo-c4="" class="btn reg-form-submit-btn"> Next
          </button></div>
      </div>
    </div>
  </div>
</form>

<form _ngcontent-fmo-c4="" autocomplete="off" class="needs-validation registration-form ng-untouched ng-pristine ng-invalid" novalidate="">
  <div _ngcontent-fmo-c4="" class="content fade dstepper-none" id="test-l-3">
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="bs-stepper-header justify-content-center d-md-none">
        <div _ngcontent-fmo-c4="" class="step" data-target="#test-l-3"><button _ngcontent-fmo-c4="" class="step-trigger" aria-selected="false"><span _ngcontent-fmo-c4="" class="bs-stepper-circle">3</span><span _ngcontent-fmo-c4=""
              class="bs-stepper-label">Validate</span></button></div>
      </div>
    </div>
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="row no-gutters">
        <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 text-right"><button _ngcontent-fmo-c4="" aria-controls="collapseExample" class="btn btn-outline-primary" id="referralButton" type="button" aria-expanded="false"><i-feather _ngcontent-fmo-c4=""
              name="share-2" _nghost-fmo-c3=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" class="feather feather-share-2">
                <circle cx="18" cy="5" r="3"></circle>
                <circle cx="6" cy="12" r="3"></circle>
                <circle cx="18" cy="19" r="3"></circle>
                <line x1="8.59" y1="13.51" x2="15.42" y2="17.49"></line>
                <line x1="15.41" y1="6.51" x2="8.59" y2="10.49"></line>
              </svg></i-feather> Referral </button></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 pd-y-10 mg-y-10">
          <div _ngcontent-fmo-c4="" id="collapseExample" class="collapse">
            <fieldset _ngcontent-fmo-c4="" class="form-fieldset">
              <legend _ngcontent-fmo-c4="">REFERENCE</legend>
              <div _ngcontent-fmo-c4="" class="row row-sm">
                <div _ngcontent-fmo-c4="" class="col-sm-12">
                  <div _ngcontent-fmo-c4="" class="row row-sm">
                    <div _ngcontent-fmo-c4="" class="col-sm-12">
                      <div _ngcontent-fmo-c4="" class="form-group row">
                        <div _ngcontent-fmo-c4="" class="col-sm-4"><label _ngcontent-fmo-c4="" class="col-form-label">Referee First Name</label></div>
                        <div _ngcontent-fmo-c4="" class="col-sm-8"><input _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-valid" formcontrolname="firstName" placeholder="Enter First Name" type="text"></div>
                      </div>
                      <div _ngcontent-fmo-c4="" class="form-group row">
                        <div _ngcontent-fmo-c4="" class="col-sm-4"><label _ngcontent-fmo-c4="" class="col-form-label">Referee Last Name</label></div>
                        <div _ngcontent-fmo-c4="" class="col-sm-8"><input _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-valid" formcontrolname="lastName" placeholder="Enter Last Name" type="text"></div>
                      </div>
                      <div _ngcontent-fmo-c4="" class="form-group row">
                        <div _ngcontent-fmo-c4="" class="col-sm-4"><label _ngcontent-fmo-c4="" class="col-form-label">Referee Email Id</label></div>
                        <div _ngcontent-fmo-c4="" class="col-sm-8"><input _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="emailId" placeholder="Enter Email Id" type="text"><!----></div>
                      </div>
                      <div _ngcontent-fmo-c4="" class="form-group row">
                        <div _ngcontent-fmo-c4="" class="col-sm-4"><label _ngcontent-fmo-c4="" class="col-form-label">Referee Phone No.</label></div>
                        <div _ngcontent-fmo-c4="" class="col-sm-8 custom"><ngx-intl-tel-input _ngcontent-fmo-c4="" formcontrolname="phoneNumber" inputid="mobile" name="phoneNumber" style="width: 100% !important" _nghost-fmo-c8=""
                            class="ng-untouched ng-valid ng-dirty">
                            <div _ngcontent-fmo-c8="" class="intl-tel-input allow-dropdown separate-dial-code iti-sdc-2">
                              <div _ngcontent-fmo-c8="" class="flag-container" dropdown="">
                                <div _ngcontent-fmo-c8="" class="selected-flag dropdown-toggle" dropdowntoggle="" aria-haspopup="true">
                                  <div _ngcontent-fmo-c8="" class="iti-flag us"></div><!---->
                                  <div _ngcontent-fmo-c8="" class="selected-dial-code ng-star-inserted">+1</div>
                                  <div _ngcontent-fmo-c8="" class="iti-arrow"></div>
                                </div><!---->
                              </div><input _ngcontent-fmo-c8="" autocomplete="off" type="tel" class="w-100 form-control custom-form-control ng-untouched ng-pristine ng-valid" id="mobile" placeholder="201-555-0123" maxlength="15" validation="true">
                            </div>
                          </ngx-intl-tel-input><!----></div>
                      </div>
                      <div _ngcontent-fmo-c4="" class="form-group row mg-t-20">
                        <div _ngcontent-fmo-c4="" class="col-sm-12 text-center"><button _ngcontent-fmo-c4="" class="btn btn-primary mg-b-5 mr-2 mg-sm-b-0" type="submit"> Refer </button><button _ngcontent-fmo-c4=""
                            class="btn btn-primary mg-b-5 mr-2 mg-sm-b-0" type="button"> Reset </button><button _ngcontent-fmo-c4="" class="btn btn-primary mg-b-5 mg-sm-b-0" type="button"> Cancel </button></div>
                      </div>
                    </div>
                  </div>
                </div>
              </div>
            </fieldset>
          </div>
        </div>
      </div>
    </div>
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="form-header mg-b-20 text-uppercase tx-spacing--1"> other information </div>
    </div>
    <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 col-xl-12">
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="profession_Id">Profession<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><ng-select _ngcontent-fmo-c4=""
            bindlabel="Name" bindvalue="RecId" formcontrolname="profession_Id" id="profession_Id" placeholder="Profession" role="listbox" class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid">
            <div class="ng-select-container">
              <div class="ng-value-container">
                <div class="ng-placeholder">Profession</div><!----><!---->
                <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a59832816a62" aria-expanded="false"></div>
              </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
            </div><!---->
          </ng-select><!----></div><!----><!---->
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group ng-star-inserted"><label _ngcontent-fmo-c4="" class="form-label" for="industry_id">Industry<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><ng-select
            _ngcontent-fmo-c4="" bindlabel="Name" bindvalue="RecId" formcontrolname="industry_id" id="industry_id" placeholder="Industry" role="listbox"
            class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-invalid">
            <div class="ng-select-container">
              <div class="ng-value-container">
                <div class="ng-placeholder">Industry</div><!----><!---->
                <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a186f811820e" aria-expanded="false"></div>
              </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
            </div><!---->
          </ng-select><!----></div><!----><!----><!----><!----><!----><!---->
        <div _ngcontent-fmo-c4="" class="col-12 col-md-12 col-lg-12 form-group ng-star-inserted">
          <div _ngcontent-fmo-c4="" class="row row-sm">
            <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="document_type">Document type<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><ng-select
                _ngcontent-fmo-c4="" bindlabel="Name" bindvalue="Name" formcontrolname="document_type" id="document_type" placeholder="Document type" role="listbox"
                class="ng-select ng-select-single ng-select-searchable ng-select-clearable ng-untouched ng-pristine ng-valid">
                <div class="ng-select-container">
                  <div class="ng-value-container">
                    <div class="ng-placeholder">Document type</div><!----><!---->
                    <div class="ng-input"><input role="combobox" type="text" autocorrect="off" autocapitalize="off" autocomplete="a5598dcf9532" aria-expanded="false"></div>
                  </div><!----><!----><span class="ng-arrow-wrapper"><span class="ng-arrow"></span></span>
                </div><!---->
              </ng-select><!----></div>
            <div _ngcontent-fmo-c4="" class="col-12 col-md-6 col-lg-4 form-group"><label _ngcontent-fmo-c4="" class="form-label" for="identification_number">Identification Number<span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input
                _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid" formcontrolname="doument_no" placeholder="Identification Number" required="" type="text"><!----></div>
          </div>
        </div>
      </div><!----><!---->
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-20 ng-star-inserted">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-12 col-lg-12 form-group">
          <div _ngcontent-fmo-c4="" class="row row-sm">
            <div _ngcontent-fmo-c4="" class="col-sm-12"><label _ngcontent-fmo-c4="" class="text-uppercase">Market Research:</label></div>
            <div _ngcontent-fmo-c4="" class="col-sm-12">
              <div _ngcontent-fmo-c4="" class="custom-control custom-checkbox mg-b-10"><input _ngcontent-fmo-c4="" checked="checked" class="custom-control-input ng-untouched ng-pristine ng-invalid" formcontrolname="isAgree_paid_survey"
                  id="isAgree_paid_survey" type="checkbox"><label _ngcontent-fmo-c4="" class="custom-control-label" for="isAgree_paid_survey" style="color: inherit !important">I would like to participate in paid market research
                  surveys.</label><!----></div>
              <div _ngcontent-fmo-c4="" class="custom-control custom-checkbox mg-b-10"><input _ngcontent-fmo-c4="" checked="checked" class="custom-control-input ng-untouched ng-pristine ng-invalid" formcontrolname="isAgree_privacy"
                  id="isAgree_privacy" type="checkbox"><label _ngcontent-fmo-c4="" class="custom-control-label" for="isAgree_privacy" style="color: inherit !important">By checking this box, you are confirming that you have read and agree to our
                  <a _ngcontent-fmo-c4="" href="../../../assets/pdf/GaZoi_Terms_of_Use.pdf" target="_blank">Terms of Use</a>, Privacy Policy and consent to the collection, processing and retention of your data in accordance with our privacy policy,
                  your identity and the opinions you provide are always kept completely confidential as stated in our
                  <a _ngcontent-fmo-c4="" href="../../../assets/pdf/GaZoi_Privacy_Cookies_Policies.pdf" target="_blank">Privacy Policy</a>.</label><!----></div>
            </div>
            <div _ngcontent-fmo-c4="" class="col-sm-12"><label _ngcontent-fmo-c4="" class="text-uppercase">NPI/Registration No.:</label></div>
            <div _ngcontent-fmo-c4="" class="col-sm-12">
              <div _ngcontent-fmo-c4="" class="custom-control custom-checkbox mg-b-10"><input _ngcontent-fmo-c4="" checked="checked" class="custom-control-input ng-untouched ng-pristine ng-invalid" formcontrolname="isDoument_Agree"
                  id="identification_number_text_checkbox" type="checkbox"><label _ngcontent-fmo-c4="" class="custom-control-label" for="identification_number_text_checkbox" style="color: inherit !important">The respondent acknowledges and consents
                  to the collection by OSG of the NPI or any other identity no. for the purpose of completing the respondent’s registration on the GaZoi platform. The respondent acknowledges and consents to OSG / GaZoi platform retaining the personal
                  information for as long as permitted or required by applicable law or business practices.</label><!----></div>
            </div>
          </div>
        </div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-b-10 mg-y-20">
        <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 form-group text-center d-flex justify-content-center"><app-captcha _ngcontent-fmo-c4="" formcontrolname="recaptcha" id="captcha" _nghost-fmo-c9="" class="ng-untouched ng-pristine ng-invalid">
            <div _ngcontent-fmo-c9="" class="custom-contactus-captcha d-flex justify-content-center align-items-center"><canvas _ngcontent-fmo-c9="" height="64" id="canvas1" style="border: 1px solid #d3d3d3" width="130"></canvas><input
                _ngcontent-fmo-c9="" class="mx-2 pd-10" id="ans" style="
      border: 1px solid #d3d3d3;
      font-size: 28px;
      font-weight: 600;
      width: 99px;
    " type="number"><button _ngcontent-fmo-c9="" class="btn btn-sm btn-primary" style="height: 64px" type="button"><i-feather _ngcontent-fmo-c9="" name="refresh-cw" _nghost-fmo-c3=""><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24"
                    class="feather feather-refresh-cw">
                    <polyline points="23 4 23 10 17 10"></polyline>
                    <polyline points="1 20 1 14 7 14"></polyline>
                    <path d="M3.51 9a9 9 0 0 1 14.85-3.36L23 10M1 14l4.64 4.36A9 9 0 0 0 20.49 15"></path>
                  </svg></i-feather></button></div>
          </app-captcha></div>
        <div _ngcontent-fmo-c4="" class="col-12 col-lg-12 text-center d-flex justify-content-center"><!----></div>
      </div>
      <div _ngcontent-fmo-c4="" class="row no-gutters form-row mg-t-30 mg-b-10 justify-content-center">
        <div _ngcontent-fmo-c4="" class="col-12 col-md-6 form-group text-center"><button _ngcontent-fmo-c4="" class="btn reg-form-submit-btn mg-r-10" type="button"> Prev </button><button _ngcontent-fmo-c4="" class="btn reg-form-submit-btn mg-r-10"
            type="submit"> Submit </button></div>
      </div>
    </div>
  </div>
</form>

<form _ngcontent-fmo-c4="" action="" class="needs-validation ng-untouched ng-pristine ng-invalid" id="form" novalidate="">
  <div _ngcontent-fmo-c4="" class="row row-sm">
    <div _ngcontent-fmo-c4="" class="col-sm-12 form-group mg-sm-t-0"><label _ngcontent-fmo-c4="">Email: <span _ngcontent-fmo-c4="" class="tx-danger">*</span></label><input _ngcontent-fmo-c4="" class="form-control ng-untouched ng-pristine ng-invalid"
        formcontrolname="email" name="email" placeholder="Please enter your email" type="email"><!----></div><!---->
    <div _ngcontent-fmo-c4="" class="col-sm-12 form-group mg-sm-t-0 ng-star-inserted"><!----><!----></div><!---->
    <div _ngcontent-fmo-c4="" class="col-sm-12 d-lg-flex justify-content-lg-center align-items-center tx-center ng-star-inserted"><!----><!----><button _ngcontent-fmo-c4="" class="btn btn-primary btn-sm pd-x-20 mx-2 ng-star-inserted" type="button">
        Send OTP </button></div><!---->
  </div>
</form>

Text Content

 * Main Navigation
 * About GaZoi
    * Who are we ?
    * How it works ?
   
   * Who are we ?
   * How it works ?
 * FAQ
 * Referral
 * Contact us

1Registration

2Registration Type

3Validate
1Registration
Salutation*Choose any oneMr.Mrs.Ms.MissDr.Prof.
First Name*
Middle Name
Last Name*

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Gender *Choose any oneMaleFemalePrefer not to answer
DOB*
Year

Month

Day

Mobile*
+1

Address*
City*
Country*
Country

State/Province*
Zip Code/Pin Code*
Email*
Set Password*
Confirm Password*
Referred by (Referral code)
Next
2Registration Type
How did you hear about GaZoi?*Choose any oneBlogDigital adDirect Mail Event &
Conference FacebookFlyerGoogle AdwordsGoogle SearchLinkedInNewspaper adPodcast
Referral from a healthcare professional Support GroupTwitter Other Social Media
Other (Please Specify below box)
Registration Type*Choose any one Non Healthcare Professional Healthcare
Professional
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3Validate
Referral
REFERENCE
Referee First Name

Referee Last Name

Referee Email Id

Referee Phone No.
+1

Refer Reset Cancel
other information
Profession*
Profession

Industry*
Industry

Document type*
Document type

Identification Number*
Market Research:
I would like to participate in paid market research surveys.
By checking this box, you are confirming that you have read and agree to our
Terms of Use, Privacy Policy and consent to the collection, processing and
retention of your data in accordance with our privacy policy, your identity and
the opinions you provide are always kept completely confidential as stated in
our Privacy Policy.
NPI/Registration No.:
The respondent acknowledges and consents to the collection by OSG of the NPI or
any other identity no. for the purpose of completing the respondent’s
registration on the GaZoi platform. The respondent acknowledges and consents to
OSG / GaZoi platform retaining the personal information for as long as permitted
or required by applicable law or business practices.

Prev Submit

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www.gazoi.com Open in urlscan Pro 54.166.116.146 Public Scan

Form analysis 4 forms found in the DOM

Text Content

www.gazoi.com Open in urlscan Pro
54.166.116.146 Public Scan

Form analysis
4 forms found in the DOM