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Form analysis
1 forms found in the DOM

POST bat/rd-mailform.php

<form class="rd-mailform" data-form-output="form-output-global" data-form-type="contact" method="post" action="bat/rd-mailform.php" novalidate="novalidate">
  <div class="range range-xs-center range-20 range-narrow">
    <div class="cell-sm-5">
      <div class="form-wrap form-wrap-validation">
        <div class="select2-container form-input select-filter form-control-has-validation" id="s2id_regula-generated-276034">
          <a href="javascript:void(0)" class="select2-choice select2-default" tabindex="-1">   <span class="select2-chosen" id="select2-chosen-1">Department</span><abbr class="select2-search-choice-close"></abbr>   <span class="select2-arrow" role="presentation"><b role="presentation"></b></span></a><label
            for="s2id_autogen1" class="select2-offscreen"></label><input class="select2-focusser select2-offscreen" type="text" aria-haspopup="true" role="button" aria-labelledby="select2-chosen-1" id="s2id_autogen1">
          <div class="select2-drop select2-display-none">
            <div class="select2-search select2-search-hidden select2-offscreen"> <label for="s2id_autogen1_search" class="select2-offscreen"></label> <input type="text" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false"
                class="select2-input" role="combobox" aria-expanded="true" aria-autocomplete="list" aria-owns="select2-results-1" id="s2id_autogen1_search" placeholder=""> </div>
            <ul class="select2-results" role="listbox" id="select2-results-1"> </ul>
          </div>
        </div><select class="form-input select-filter form-control-has-validation" data-style="modern" data-placeholder="Department" data-minimum-results-for-search="Infinity" data-constraints="@Required" id="regula-generated-276034" tabindex="-1"
          title="" style="display: none;">
          <option label="placeholder"></option>
          <option value="2">Appointment</option>
          <option value="3">Billing</option>
          <option value="4">General</option>
          <option value="5">Medical Record</option>
        </select><span class="form-validation"></span><span class="select-arrow"></span>
      </div>
    </div>
    <div class="cell-sm-5">
      <div class="form-wrap form-wrap-validation">
        <label class="form-label rd-input-label" for="forms-name">Your Name</label>
        <input class="form-input form-control-has-validation form-control-last-child" id="forms-name" type="text" name="name" data-constraints="@Required"><span class="form-validation"></span>
      </div>
    </div>
    <div class="cell-sm-5">
      <div class="form-wrap form-wrap-validation">
        <label class="form-label rd-input-label" for="forms-date">Date of Birth</label>
        <input class="form-input form-control-has-validation form-control-last-child" id="forms-date" type="text" name="name" data-constraints="@Required"><span class="form-validation"></span>
      </div>
    </div>
    <div class="cell-sm-5">
      <div class="form-wrap form-wrap-validation">
        <label class="form-label rd-input-label" for="forms-phone">Phone</label>
        <input class="form-input form-control-has-validation form-control-last-child" id="forms-phone" type="text" name="phone" data-constraints="@Numeric @Required"><span class="form-validation"></span>
      </div>
    </div>
    <div class="cell-sm-10">
      <div class="form-wrap form-wrap-validation">
        <label class="form-label rd-input-label" for="forms-message">Your Message</label>
        <textarea class="form-input form-control-has-validation form-control-last-child" id="forms-message" name="message" data-constraints="@Required"></textarea><span class="form-validation"></span>
      </div>
    </div>
    <div class="cell-sm-5">
      <div class="form-wrap form-wrap-validation">
        <label class="form-label rd-input-label" for="forms-email">E-mail</label>
        <input class="form-input form-control-has-validation form-control-last-child" id="forms-email" type="email" name="email" data-constraints="@Email @Required"><span class="form-validation"></span>
      </div>
    </div>
    <div class="cell-sm-5">
      <div class="form-button">
        <button class="button button-effect-ujarak button-primary button-block button-square" type="submit">send message</button>
      </div>
    </div>
  </div>
</form>

Text Content

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 * 227 N Jackson Avenue Suite 235, San Jose, CA 95116
 * 1661 Burdette Drive, Suite N, San Jose, CA 95121
 * Monday to Friday: 9 AM - 6 PM
   

(408) 254-9192
 * Home
 * About
 * Providers
 * Services
 * Patients
     
   * COVID-19
   
 * Contacts

(408) 254-9192


CONTACT US


 * Home
 * Contact Us

THANK YOU FOR YOUR INTEREST IN ONE HEALTH PRIMARY CARE

For questions or concerns about your care or service, please contact us. Most
inquiries will receive a response within 2-3 business days.

 * If you are experiencing a medical emergency, call 9-1-1 immediately or go to
   the emergency room.
 * If you are requesting medical advice, need immediate assistance or want to
   schedule/cancel an appointment, call (408) 254-9192.



IF YOU THINK YOU ARE SICK, NOTIFY YOUR PROVIDER BEFORE ARRIVING AT THE CLINIC IF
POSSIBLE.

This will help ensure staff make the most appropriate disease control
preparations. Please wear a face covering for all in-person clinic visits.


CONTACT US

For general questions or additional information, please complete this form:

Department

Appointment Billing General Medical Record
Your Name
Date of Birth
Phone
Your Message
E-mail
send message

ONE HEALTH PRIMARY CARE


 * * About
   * Services
 * * Providers
   * Patients
 * * Contact

CONTACT US


 * +1 (408) 254-9192
 * contact@onehealthmed.org

CLINIC ADDRESS


 * 227 N Jackson Avenue,
   Suite 235
   San Jose, CA 95116
 * 1661 Burdette Drive, Suite N
   San Jose, CA 95121

ONE HEALTH PRIMARY CARE © 2024. Privacy Policy