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104.16.21.84  Public Scan

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Submitted URL: https://click.email.teladochealth.com/?qs=e1516c4e5aa508e818ba0a3b19ab190aeb1464bdd4e596997c503749d29fa2a611b17a5e133c997659dc2b3bb6c7...
Effective URL: https://member.teladoc.com/registrations/get_started?pk_campaign=Q42022-lb-Nov-NonInc-25&pk_source=non-reg&pk_medium=email&...
Submission: On December 14 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

<form class="f1b76ey0 form-container">
  <div class="f10jhm76" id="red-error-msg" role="alert" tabindex="0" hidden="" aria-describedby="red_error_message" aria-label="Error">
    <div id="red_error_message" class="warning">
      <div class="fyj5ofj foundation-style">To continue, please fill in or correct the fields marked with red text.<br> If you need help, call us at 1-800-Teladoc (1-800-835-2362).</div>
    </div>
    <div class="error-list">
      <div class="fngxb1j foundation-style"></div>
    </div>
  </div>
  <div class="fngxb1j foundation-style registration-field-container">
    <div class="f1vfyt1j foundation-style fo077u4">
      <div>
        <div class="f1mgyl9u">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="first_name" tabindex="-1">First Name</label><input id="first_name" type="text" inputmode="text" class="fjq2s7n foundation-style" maxlength="300" placeholder=""
            name="firstName" role="textbox" aria-label="First Name" aria-required="true" value="">
          <div class="input-bar f8ce5bf"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="fngxb1j foundation-style registration-field-container">
    <div class="f1vfyt1j foundation-style fo077u4">
      <div>
        <div class="f1mgyl9u">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="last_name" tabindex="-1">Last Name</label><input id="last_name" type="text" inputmode="text" class="fjq2s7n foundation-style" maxlength="300" placeholder=""
            name="lastName" role="textbox" aria-label="Last Name" aria-required="true" value="">
          <div class="input-bar f8ce5bf"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="fngxb1j foundation-style registration-field-container">
    <div class="f1vfyt1j foundation-style fo077u4">
      <div class="date-of-birth " aria-describedby="date-of-birth-label"><span id="date-of-birth-label">Date Of Birth:</span>
        <div class="container-dob ">
          <div class="row-m-d">
            <div class="field" aria-label="Date Of Birth"><label for="month">Month</label><input type="text" id="month" maxlength="2" name="month" aria-required="true" aria-describedby="month" placeholder="MM" inputmode="numeric" value=""></div>
            <div class="field" aria-label="Date Of Birth"><label for="day">Day</label><input type="text" id="day" maxlength="2" name="day" aria-required="true" aria-describedby="day" placeholder="DD" inputmode="numeric" value=""></div>
          </div>
          <div class="field year" aria-label="Date Of Birth"><label for="year">Year</label><input type="text" id="year" maxlength="4" name="year" aria-required="true" aria-describedby="year" placeholder="YYYY" inputmode="numeric" value=""></div>
        </div>
      </div>
    </div>
  </div>
  <div class="fngxb1j foundation-style registration-field-container">
    <div class="f14pfxr4 foundation-style fo077u4">
      <div>
        <div class="f1gfcnll">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="country_cd" tabindex="-1">Country</label><select id="country_cd" name="countryCd" class="f1rt5r2 foundation-style">
            <option value="USA">United States Of America</option>
            <option value="CAN">Canada</option>
            <option value="DNK">Denmark</option>
            <option value="AFG">Afghanistan</option>
            <option value="ALB">Albania</option>
            <option value="DZA">Algeria</option>
            <option value="ASM">American Samoa</option>
            <option value="AND">Andorra</option>
            <option value="AGO">Angola</option>
            <option value="AIA">Anguilla</option>
            <option value="ATA">Antarctica</option>
            <option value="ATG">Antigua and Barbuda</option>
            <option value="ARG">Argentina</option>
            <option value="ARM">Armenia</option>
            <option value="ABW">Aruba</option>
            <option value="AUS">Australia</option>
            <option value="AUT">Austria</option>
            <option value="AZE">Azerbaijan</option>
            <option value="BHS">Bahamas</option>
            <option value="BHR">Bahrain</option>
            <option value="BGD">Bangladesh</option>
            <option value="BRB">Barbados</option>
            <option value="BLR">Belarus</option>
            <option value="BEL">Belgium</option>
            <option value="BLZ">Belize</option>
            <option value="BEN">Benin</option>
            <option value="BMU">Bermuda</option>
            <option value="BTN">Bhutan</option>
            <option value="BOL">Bolivia</option>
            <option value="BES">Bonaire</option>
            <option value="BIH">Bosnia and Herzegovina</option>
            <option value="BWA">Botswana</option>
            <option value="BRA">Brazil</option>
            <option value="IOT">British Indian Ocean Territory</option>
            <option value="VGB">British Virgin Islands</option>
            <option value="BRN">Brunei</option>
            <option value="BGR">Bulgaria</option>
            <option value="BFA">Burkina Faso</option>
            <option value="BDI">Burundi</option>
            <option value="KHM">Cambodia</option>
            <option value="CMR">Cameroon</option>
            <option value="CPV">Cape Verde</option>
            <option value="CYM">Cayman Islands</option>
            <option value="CAF">Central African Republic</option>
            <option value="TCD">Chad</option>
            <option value="CHL">Chile</option>
            <option value="CHN">China</option>
            <option value="CXR">Christmas Island</option>
            <option value="CCK">Cocos [Keeling] Islands</option>
            <option value="COL">Colombia</option>
            <option value="COM">Comoros</option>
            <option value="COK">Cook Islands</option>
            <option value="CRI">Costa Rica</option>
            <option value="HRV">Croatia</option>
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            <option value="CUW">Curacao</option>
            <option value="CYP">Cyprus</option>
            <option value="CZE">Czechia</option>
            <option value="COD">Democratic Republic of the Congo</option>
            <option value="DJI">Djibouti</option>
            <option value="DMA">Dominica</option>
            <option value="DOM">Dominican Republic</option>
            <option value="TLS">East Timor</option>
            <option value="ECU">Ecuador</option>
            <option value="EGY">Egypt</option>
            <option value="SLV">El Salvador</option>
            <option value="GNQ">Equatorial Guinea</option>
            <option value="ERI">Eritrea</option>
            <option value="EST">Estonia</option>
            <option value="ETH">Ethiopia</option>
            <option value="FLK">Falkland Islands</option>
            <option value="FRO">Faroe Islands</option>
            <option value="FJI">Fiji</option>
            <option value="FIN">Finland</option>
            <option value="FRA">France</option>
            <option value="GUF">French Guiana</option>
            <option value="PYF">French Polynesia</option>
            <option value="ATF">French Southern Territories</option>
            <option value="GAB">Gabon</option>
            <option value="GMB">Gambia</option>
            <option value="GEO">Georgia</option>
            <option value="DEU">Germany</option>
            <option value="GHA">Ghana</option>
            <option value="GIB">Gibraltar</option>
            <option value="GRC">Greece</option>
            <option value="GRL">Greenland</option>
            <option value="GRD">Grenada</option>
            <option value="GLP">Guadeloupe</option>
            <option value="GTM">Guatemala</option>
            <option value="GGY">Guernsey</option>
            <option value="GIN">Guinea</option>
            <option value="GNB">Guinea-Bissau</option>
            <option value="GUY">Guyana</option>
            <option value="HTI">Haiti</option>
            <option value="HND">Honduras</option>
            <option value="HKG">Hong Kong</option>
            <option value="HUN">Hungary</option>
            <option value="ISL">Iceland</option>
            <option value="IND">India</option>
            <option value="IDN">Indonesia</option>
            <option value="IRN">Iran</option>
            <option value="IRQ">Iraq</option>
            <option value="IRL">Ireland</option>
            <option value="IMN">Isle of Man</option>
            <option value="ISR">Israel</option>
            <option value="ITA">Italy</option>
            <option value="CIV">Ivory Coast</option>
            <option value="JAM">Jamaica</option>
            <option value="JPN">Japan</option>
            <option value="JEY">Jersey</option>
            <option value="JOR">Jordan</option>
            <option value="KAZ">Kazakhstan</option>
            <option value="KEN">Kenya</option>
            <option value="KIR">Kiribati</option>
            <option value="XKX">Kosovo</option>
            <option value="KWT">Kuwait</option>
            <option value="KGZ">Kyrgyzstan</option>
            <option value="LAO">Laos</option>
            <option value="LVA">Latvia</option>
            <option value="LBN">Lebanon</option>
            <option value="LSO">Lesotho</option>
            <option value="LBR">Liberia</option>
            <option value="LBY">Libya</option>
            <option value="LIE">Liechtenstein</option>
            <option value="LTU">Lithuania</option>
            <option value="LUX">Luxembourg</option>
            <option value="MAC">Macao</option>
            <option value="MKD">Macedonia</option>
            <option value="MDG">Madagascar</option>
            <option value="MWI">Malawi</option>
            <option value="MYS">Malaysia</option>
            <option value="MDV">Maldives</option>
            <option value="MLI">Mali</option>
            <option value="MLT">Malta</option>
            <option value="MHL">Marshall Islands</option>
            <option value="MTQ">Martinique</option>
            <option value="MRT">Mauritania</option>
            <option value="MUS">Mauritius</option>
            <option value="MYT">Mayotte</option>
            <option value="MEX">Mexico</option>
            <option value="FSM">Micronesia</option>
            <option value="MDA">Moldova</option>
            <option value="MCO">Monaco</option>
            <option value="MNG">Mongolia</option>
            <option value="MNE">Montenegro</option>
            <option value="MSR">Montserrat</option>
            <option value="MAR">Morocco</option>
            <option value="MOZ">Mozambique</option>
            <option value="MMR">Myanmar [Burma]</option>
            <option value="NAM">Namibia</option>
            <option value="NRU">Nauru</option>
            <option value="NPL">Nepal</option>
            <option value="NLD">Netherlands</option>
            <option value="ANT">Netherlands Antilles</option>
            <option value="NCL">New Caledonia</option>
            <option value="NZL">New Zealand</option>
            <option value="NIC">Nicaragua</option>
            <option value="NER">Niger</option>
            <option value="NGA">Nigeria</option>
            <option value="NIU">Niue</option>
            <option value="NFK">Norfolk Island</option>
            <option value="PRK">North Korea</option>
            <option value="NOR">Norway</option>
            <option value="OMN">Oman</option>
            <option value="PAK">Pakistan</option>
            <option value="PLW">Palau</option>
            <option value="PSE">Palestine</option>
            <option value="PAN">Panama</option>
            <option value="PNG">Papua New Guinea</option>
            <option value="PRY">Paraguay</option>
            <option value="PER">Peru</option>
            <option value="PHL">Philippines</option>
            <option value="PCN">Pitcairn Islands</option>
            <option value="POL">Poland</option>
            <option value="PRT">Portugal</option>
            <option value="QAT">Qatar</option>
            <option value="COG">Republic of the Congo</option>
            <option value="ROU">Romania</option>
            <option value="RUS">Russia</option>
            <option value="RWA">Rwanda</option>
            <option value="SHN">Saint Helena</option>
            <option value="KNA">Saint Kitts and Nevis</option>
            <option value="LCA">Saint Lucia</option>
            <option value="MAF">Saint Martin</option>
            <option value="SPM">Saint Pierre and Miquelon</option>
            <option value="VCT">Saint Vincent and the Grenadines</option>
            <option value="WSM">Samoa</option>
            <option value="SMR">San Marino</option>
            <option value="SAU">Saudi Arabia</option>
            <option value="SEN">Senegal</option>
            <option value="SRB">Serbia</option>
            <option value="SCG">Serbia and Montenegro</option>
            <option value="SYC">Seychelles</option>
            <option value="SLE">Sierra Leone</option>
            <option value="SGP">Singapore</option>
            <option value="SXM">Sint Maarten</option>
            <option value="SVK">Slovakia</option>
            <option value="SVN">Slovenia</option>
            <option value="SLB">Solomon Islands</option>
            <option value="SOM">Somalia</option>
            <option value="ZAF">South Africa</option>
            <option value="SGS">South Georgia and the South Sandwich Islands</option>
            <option value="KOR">South Korea</option>
            <option value="SSD">South Sudan</option>
            <option value="ESP">Spain</option>
            <option value="LKA">Sri Lanka</option>
            <option value="SDN">Sudan</option>
            <option value="SUR">Suriname</option>
            <option value="SJM">Svalbard and Jan Mayen</option>
            <option value="SWZ">Swaziland</option>
            <option value="SWE">Sweden</option>
            <option value="CHE">Switzerland</option>
            <option value="SYR">Syria</option>
            <option value="TWN">Taiwan</option>
            <option value="TJK">Tajikistan</option>
            <option value="TZA">Tanzania</option>
            <option value="THA">Thailand</option>
            <option value="TGO">Togo</option>
            <option value="TKL">Tokelau</option>
            <option value="TON">Tonga</option>
            <option value="TTO">Trinidad and Tobago</option>
            <option value="TUN">Tunisia</option>
            <option value="TUR">Turkey</option>
            <option value="TKM">Turkmenistan</option>
            <option value="TCA">Turks and Caicos Islands</option>
            <option value="TUV">Tuvalu</option>
            <option value="UMI">U.S. Minor Outlying Islands</option>
            <option value="UGA">Uganda</option>
            <option value="UKR">Ukraine</option>
            <option value="ARE">United Arab Emirates</option>
            <option value="GBR">United Kingdom</option>
            <option value="URY">Uruguay</option>
            <option value="UZB">Uzbekistan</option>
            <option value="VUT">Vanuatu</option>
            <option value="VAT">Vatican City</option>
            <option value="VEN">Venezuela</option>
            <option value="VNM">Vietnam</option>
            <option value="WLF">Wallis and Futuna</option>
            <option value="ESH">Western Sahara</option>
            <option value="YEM">Yemen</option>
            <option value="ZMB">Zambia</option>
            <option value="ZWE">Zimbabwe</option>
          </select>
          <div class="input-bar f8ce5bf"></div>
        </div>
        <div></div>
      </div>
    </div>
    <div class="f1vfyt1j foundation-style fo077u4">
      <div>
        <div class="f1mgyl9u">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="postal" tabindex="-1">Zip Code</label><input id="postal" type="text" inputmode="numeric" class="fjq2s7n foundation-style" maxlength="300"
            placeholder="11111 or 11111-1111" name="zipCode" role="textbox" aria-label="Zip Code" aria-required="true" value="">
          <div class="input-bar f8ce5bf"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="fngxb1j foundation-style registration-field-container">
    <div class="f1vfyt1j foundation-style fo077u4">
      <div>
        <div class="f1mgyl9u">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="email_address" tabindex="-1">Email</label><input id="email_address" type="text" inputmode="text" class="fjq2s7n foundation-style" maxlength="300" placeholder=""
            name="emailAddress" role="textbox" aria-label="Email" aria-required="true" value="">
          <div class="input-bar f8ce5bf"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="fngxb1j foundation-style registration-field-container">
    <div class="f14pfxr4 foundation-style fo077u4">
      <div>
        <div class="f1gfcnll">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="language" tabindex="-1">Preferred Language</label><select id="language" name="language" class="f1rt5r2 foundation-style">
            <option value=""></option>
            <option value="American Sign Language">American Sign Language</option>
            <option value="Arabic">Arabic</option>
            <option value="Danish">Danish</option>
            <option value="English">English</option>
            <option value="French">French</option>
            <option value="German">German</option>
            <option value="Hindi">Hindi</option>
            <option value="Japanese">Japanese</option>
            <option value="Korean">Korean</option>
            <option value="Mandarin">Mandarin</option>
            <option value="Portuguese">Portuguese</option>
            <option value="Russian">Russian</option>
            <option value="Spanish">Spanish</option>
            <option value="Turkish">Turkish</option>
            <option value="Vietnamese">Vietnamese</option>
            <option value="Other">Other</option>
          </select>
          <div class="input-bar f8ce5bf"></div>
        </div>
        <div></div>
      </div>
    </div>
    <div class="f1vfyt1j foundation-style fo077u4">
      <div>
        <div class="f1gfcnll">
          <div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="gender" tabindex="-1">Biological Sex</label><select id="gender" name="gender" class="f1rt5r2 foundation-style">
            <option value="">Please Select</option>
            <option value="GENDER_MALE">Male</option>
            <option value="GENDER_FEMALE">Female</option>
            <option value="GENDER_OTHER">Other</option>
          </select>
          <div class="input-bar f8ce5bf"></div>
        </div>
        <div></div>
      </div>
    </div>
  </div>
  <div class="fngxb1j foundation-style promo-code-container">
    <div class="f1vfyt1j foundation-style fo077u4">
      <div>
        <div class="f1f1ygnm"><input type="checkbox" name="hasPromoCode" id="has_promo_code" aria-label="I have a Teladoc Promo Code. (Optional)" class="f10mchk9 foundation-style" value="true"><label for="has_promo_code" class="" tabindex="-1"
            aria-hidden="true"><span></span>I have a Teladoc Promo Code. (Optional)</label></div>
      </div>
    </div>
  </div>
  <div class="fyj5ofj foundation-style">
    <div class="f1vfyt1j foundation-style continue-registration-button-container"><button id="continue-registration-button" class="cta-button blue chevron" type="submit" style="margin: 0px auto;"><span>Continue</span></button></div>
  </div>
</form>

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First Name


Last Name

Date Of Birth:
Month
Day
Year

CountryUnited States Of AmericaCanadaDenmarkAfghanistanAlbaniaAlgeriaAmerican
SamoaAndorraAngolaAnguillaAntarcticaAntigua and
BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia
and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBritish Virgin
IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman
IslandsCentral African RepublicChadChileChinaChristmas IslandCocos [Keeling]
IslandsColombiaComorosCook IslandsCosta
RicaCroatiaCubaCuracaoCyprusCzechiaDemocratic Republic of the
CongoDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl
SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe
IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern
TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong
KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory
CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall
IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar
[Burma]NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew
ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth
KoreaNorwayOmanPakistanPalauPalestinePanamaPapua New
GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalQatarRepublic of the
CongoRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint
MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan
MarinoSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra
LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth
AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri
LankaSudanSurinameSvalbard and Jan
MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad
and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor
Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited
KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and
FutunaWestern SaharaYemenZambiaZimbabwe



Zip Code


Email


Preferred LanguageAmerican Sign
LanguageArabicDanishEnglishFrenchGermanHindiJapaneseKoreanMandarinPortugueseRussianSpanishTurkishVietnameseOther



Biological SexPlease SelectMaleFemaleOther


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