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2a04:4e42:600::740  Public Scan

Form analysis
1 forms found in the DOM

POST /refer-dental-provider

<form role="form" class="webform-client-form webform-client-form-450" id="webform-uuid-0a5fc265-eb3f-497f-a7d4-820c45ef6a85" novalidate="1" action="/refer-dental-provider" method="post" accept-charset="UTF-8">
  <div>
    <div class="form-item webform-component webform-component-textfield webform-component--dentists-name form-group">
      <label class="control-label" for="edit-submitted-dentists-name">Dentist's First Name <span aria-hidden="true" class="is-required"></span></label>
      <input required="required" class="form-control form-text required viewsImplicitFormSubmission-processed" type="text" id="edit-submitted-dentists-name" name="submitted[dentists_name]" value="" size="60" maxlength="150">
    </div>
    <div class="form-item webform-component webform-component-textfield webform-component--dentists-last-name form-group">
      <label class="control-label" for="edit-submitted-dentists-last-name">Dentist's Last Name <span aria-hidden="true" class="is-required"></span></label>
      <input required="required" class="form-control form-text required viewsImplicitFormSubmission-processed" type="text" id="edit-submitted-dentists-last-name" name="submitted[dentists_last_name]" value="" size="60" maxlength="128">
    </div>
    <div class="form-item webform-component webform-component-textfield webform-component--dentists-address form-group">
      <label class="control-label" for="edit-submitted-dentists-address">Dentist's Address <span aria-hidden="true" class="is-required"></span></label>
      <input required="required" class="form-control form-text required viewsImplicitFormSubmission-processed" type="text" id="edit-submitted-dentists-address" name="submitted[dentists_address]" value="" size="60" maxlength="150">
    </div>
    <div class="form-item webform-component webform-component-select webform-component--dentists-specialty form-group">
      <label class="control-label" for="edit-submitted-dentists-specialty">Dentist's Specialty <span aria-hidden="true" class="is-required"></span></label>
      <select required="required" class="form-control form-select required" id="edit-submitted-dentists-specialty" name="submitted[dentists_specialty]">
        <option value="" selected="selected">-Select-</option>
        <option value="General_Dentist">General Dentist</option>
        <option value="Endodontist_RootCanal">Endodontist (Root Canal Specialist)</option>
        <option value="Pedodontist_ChildDental">Pedodontist (Child Dental Specialist)</option>
        <option value="Periodontist_Gum">Periodontist (Gum Specialist)</option>
        <option value="Oral_Surgeon_ExtractionsSurgery">Oral Surgeon (Extractions/Surgery)</option>
        <option value="Orthodontist_Braces">Orthodontist (Braces)</option>
      </select>
    </div>
    <div class="form-item webform-component webform-component-textfield webform-component--city form-group">
      <label class="control-label" for="edit-submitted-city">City <span aria-hidden="true" class="is-required"></span></label>
      <input required="required" class="form-control form-text required viewsImplicitFormSubmission-processed" type="text" id="edit-submitted-city" name="submitted[city]" value="" size="60" maxlength="150">
    </div>
    <div class="form-item webform-component webform-component-select webform-component--state form-group">
      <label class="control-label" for="edit-submitted-state">State <span aria-hidden="true" class="is-required"></span></label>
      <select required="required" class="form-control form-select required" id="edit-submitted-state" name="submitted[state]">
        <option value="" selected="selected">-Select-</option>
        <option value="Alabama">AL</option>
        <option value="Alaska">AK</option>
        <option value="Arizona">AZ</option>
        <option value="Arkansas">AR</option>
        <option value="California">CA</option>
        <option value="Colorado">CO</option>
        <option value="Connecticut">CT</option>
        <option value="Delaware">DE</option>
        <option value="District_of_Columbia">DC</option>
        <option value="Florida">FL</option>
        <option value="Georgia">GA</option>
        <option value="Hawaii">HI</option>
        <option value="Idaho">ID</option>
        <option value="Illinois">IL</option>
        <option value="Indiana">IN</option>
        <option value="Iowa">IA</option>
        <option value="Kansas">KS</option>
        <option value="Kentucky">KY</option>
        <option value="Louisiana">LA</option>
        <option value="Maine">ME</option>
        <option value="Maryland">MD</option>
        <option value="Massachusetts">MA</option>
        <option value="Michigan">MI</option>
        <option value="Minnesota">MN</option>
        <option value="Mississippi">MS</option>
        <option value="Missouri">MO</option>
        <option value="Montana">MT</option>
        <option value="Nebraska">NE</option>
        <option value="Nevada">NV</option>
        <option value="New_Hampshire">NH</option>
        <option value="New_Jersey">NJ</option>
        <option value="New_Mexico">NM</option>
        <option value="New_York">NY</option>
        <option value="North_Carolina">NC</option>
        <option value="North_Dakota">ND</option>
        <option value="Ohio">OH</option>
        <option value="Oklahoma">OK</option>
        <option value="Oregon">OR</option>
        <option value="Pennsylvania">PA</option>
        <option value="Puerto_Rico">PR</option>
        <option value="Rhode_Island">RI</option>
        <option value="South_Carolina">SC</option>
        <option value="South_Dakota">SD</option>
        <option value="Tennessee">TN</option>
        <option value="Texas">TX</option>
        <option value="Utah">UT</option>
        <option value="Vermont">VT</option>
        <option value="Virginia">VA</option>
        <option value="Washington">WA</option>
        <option value="West_Virginia">WV</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
      </select>
    </div>
    <div class="form-item webform-component webform-component-number webform-component--zip form-group">
      <label class="control-label" for="edit-submitted-zip">Zip <span aria-hidden="true" class="is-required"></span></label>
      <input required="required" class="form-control form-text form-number required viewsImplicitFormSubmission-processed" type="text" id="edit-submitted-zip" name="submitted[zip]" step="any">
    </div>
    <div class="form-item webform-component webform-component-phone webform-component--dentists-phone-number form-group">
      <label class="control-label" for="edit-submitted-dentists-phone-number">Dentist's Phone Number <span aria-hidden="true" class="is-required"></span></label>
      <input required="required" class="form-control form-text required" type="tel" id="edit-submitted-dentists-phone-number" name="submitted[dentists_phone_number]" value="" size="17" maxlength="15">
    </div>
    <div class="form-item webform-component webform-component-markup webform-component--your-information form-group">
      <h2>Your Information</h2>
    </div>
    <div class="form-item webform-component webform-component-select webform-component--i-am-a form-group">
      <label class="control-label" for="edit-submitted-i-am-a">I am a <span aria-hidden="true" class="is-required"></span></label>
      <select required="required" class="form-control form-select required" id="edit-submitted-i-am-a" name="submitted[i_am_a]">
        <option value="" selected="selected">-Select-</option>
        <option value="agent_broker">Agent/Broker</option>
        <option value="dentist">Dentist</option>
        <option value="patient">Patient</option>
      </select>
    </div>
    <div class="form-item webform-component webform-component-textfield webform-component--your-name form-group">
      <label class="control-label" for="edit-submitted-your-name">Your Name </label>
      <input class="form-control form-text viewsImplicitFormSubmission-processed" type="text" id="edit-submitted-your-name" name="submitted[your_name]" value="" size="60" maxlength="150">
      <div class="description"><span class="help-block">Let us tell your doctor how much you appreciate them. By sharing your name here, we're able to let him or her know you made the referral.</span></div>
    </div><input type="hidden" name="details[sid]">
    <input type="hidden" name="details[page_num]" value="1">
    <input type="hidden" name="details[page_count]" value="1">
    <input type="hidden" name="details[finished]" value="0">
    <input type="hidden" name="form_build_id" value="form-viAKYp-bI4-X6dvynjI8AEmoaCMWGPqFaoa_LvgTHlo">
    <input type="hidden" name="form_id" value="webform_client_form_450">
    <div class="hidden">
      <div class="form-type-textfield form-item-url form-group">
        <label class="control-label" for="edit-url">Leave this field blank. </label>
        <input autocomplete="off" class="form-control form-text viewsImplicitFormSubmission-processed" type="text" id="edit-url" name="url" value="" size="20" maxlength="128">
      </div>
    </div>
    <div class="form-actions"><button class="webform-submit button-primary btn-primary btn form-submit" type="submit" name="op" value="Submit">Submit</button>
    </div>
  </div>
</form>

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REFER A DENTAL PROVIDER

If you were unable to find your dentist of choice, use this form to refer him or
her to the Principal Plan Dental Network. Each applicant is reviewed with
respect to utilization profiles, malpractice coverage, history, licensing, and
sanctions. Accepted providers are continually monitored to ensure a quality
network.

Required
Dentist's First Name
Dentist's Last Name
Dentist's Address
Dentist's Specialty -Select-General DentistEndodontist (Root Canal
Specialist)Pedodontist (Child Dental Specialist)Periodontist (Gum
Specialist)Oral Surgeon (Extractions/Surgery)Orthodontist (Braces)
City
State
-Select-ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWisconsinWyoming
Zip
Dentist's Phone Number


YOUR INFORMATION

I am a -Select-Agent/BrokerDentistPatient
Your Name
Let us tell your doctor how much you appreciate them. By sharing your name here,
we're able to let him or her know you made the referral.
Leave this field blank.
Submit

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