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Form analysis
2 forms found in the DOM

POST /create-contact.php

<form id="contact-form" class="contact__form" method="post" action="/create-contact.php">
  <div class="row">
    <div class="col-6 mt-3">
      <input type="text" id="name" name="name" class="form-control" placeholder="Full name">
    </div>
    <div class="col-6 mt-3">
      <input type="email" id="email" name="email" class="form-control" placeholder="Email address">
    </div>
    <div class="col-6 mt-3">
      <input type="text" id="dob" name="dob" class="form-control" placeholder="Your Date of Birth">
    </div>
    <div class="col-6 mt-3">
      <input type="text" id="phone" name="phone_number" class="form-control" placeholder="Phone number">
    </div>
    <div class="col-6 mt-3">
      <input type="text" id="state" name="state" class="form-control" placeholder="Your State">
    </div>
    <div class="col-6 mt-3">
      <input type="text" id="city" name="city" class="form-control" placeholder="Your City">
    </div>
    <div class="col-12 mt-3">
      <textarea id="street" name="street" class="form-control" rows="5" placeholder="Your street"></textarea>
    </div>
    <div class="m-3">
      <input type="checkbox" name="agreement" value="1"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from LIFELINEHEALTH LLC. Message frequency may vary. Reply STOP to cancel,
      Reply HELP for contact information. message and date rates may apply <a href="terms-conditions.html">Terms &amp; Conditions</a> | <a href="privacy-policy.html">Privacy Policy</a>
    </div>
    <div class="col-12 text-center">
      <button class="btn btn-primary" type="submit">Send</button>
    </div>
  </div>
</form>

POST /opt-contact.php

<form method="POST" action="/opt-contact.php">
  <div class="modal-body"><input type="text" class="form-control" placeholder="Phone" name="ph" required="">
  </div>
  <div class="modal-footer">
    <button type="button" class="btn btn-secondary closeModalButton">Close</button>
    <button type="submit" class="btn btn-primary">Submit</button>
  </div>
</form>

Text Content

LIFELINEHEALTH LLC
 * Home(current)
 * Terms Conditions(current)
 * Privacy Policy(current)


LIFELINEHEALTH LLC


COMPREHENSIVE SERVICES

PERSONALIZED HEALTH INSURANCE PLANS

Let us help you find the perfect health insurance plan for you and your family.
We take into account your specific needs and budget to ensure complete coverage
and peace of mind.

AFFORDABLE COVERAGE FOR INDIVIDUALS AND FAMILIES

We understand the importance of having quality health insurance at an affordable
price. Our team will work with you to find the best options available, tailored
to your unique situation.

EXPERT GUIDANCE ON HEALTH INSURANCE OPTIONS

Navigating the world of health insurance can be overwhelming. Let our
experienced advisors guide you through the process, providing valuable insight
and advice every step of the way.


MARIO MELUCCI

I'm a licensed health insurance advisor with experience and success on
effectively helping families and individuals find and secure the right
affordable health coverage that meets their every health need and budget.


HOW TO REACH US

I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from LIFELINEHEALTH LLC. Message
frequency may vary. Reply STOP to cancel, Reply HELP for contact information.
message and date rates may apply Terms & Conditions | Privacy Policy
Send

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