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Submitted URL: https://mdnt.io/e/jbeEri4gnKb
Effective URL: https://patient.modento.io/advanced-dental-center-preston/check-access/date-of-birth?route=form-request.show&back=https%3A%...
Submission: On June 12 via manual from US — Scanned from DE
Effective URL: https://patient.modento.io/advanced-dental-center-preston/check-access/date-of-birth?route=form-request.show&back=https%3A%...
Submission: On June 12 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST https://patient.modento.io/advanced-dental-center-preston/check-access/date-of-birth?back=https%3A%2F%2Fpatient.modento.io%2Fadvanced-dental-center-preston%2Fform-request%2F54573129%3Fexpires%3D1718219292%26signature%3D2ef98d67710b3850ee867e5fa9bd2fb9d6c9504b7f7c8b6827900054cf3347b6&route=form-request.show
<form method="POST"
action="https://patient.modento.io/advanced-dental-center-preston/check-access/date-of-birth?back=https%3A%2F%2Fpatient.modento.io%2Fadvanced-dental-center-preston%2Fform-request%2F54573129%3Fexpires%3D1718219292%26signature%3D2ef98d67710b3850ee867e5fa9bd2fb9d6c9504b7f7c8b6827900054cf3347b6&route=form-request.show"
accept-charset="UTF-8" id="check-access-by-birth-date"><input name="_token" type="hidden">
<div class="input-field">
<input id="initials" type="text" name="initials" placeholder="XY" autofocus="" maxlength="2">
<label for="initials" class="active"> Enter patient's initials <small> (first letter of first name and last name) </small>
</label>
</div>
</form>Text Content
You are using a browser that is not fully supported and not everything may work. We recommend using Google Chrome, Apple Safari or Mozilla Firefox. ADVANCED DENTAL CENTER - OKOLONA 8517 Preston Highway, Louisville KY 40219 * tel. (502) 966-4367 * pt.care@louisvilleadvanceddental.com * www.louisvilleadvanceddental.com/ ADVANCED DENTAL CENTER - OKOLONA 8517 Preston Highway, Louisville KY 40219 * tel. (502) 966-4367 * pt.care@louisvilleadvanceddental.com * www.louisvilleadvanceddental.com/ CHECK ACCESS Our goal is to make sure your experience is as positive as possible, and this is why we provide you this opportunity to complete your patient forms digitally before the appointment. If for whatever reason, the system is not working as expected or you have any concerns providing your information digitally, you will have an opportunity to complete your forms at the office before your appointment. Enter patient's initials (first letter of first name and last name) This online form system is fully secure and HIPAA-compliant. The information gathered during the process of filling the forms is not used anywhere outside your dental office. Submit east 8517 Preston Highway, Louisville KY 40219 * tel. (502) 966-4367 * pt.care@louisvilleadvanceddental.com * www.louisvilleadvanceddental.com/