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Submitted URL: https://u14209785.ct.sendgrid.net/ls/click?upn=u001.7INBLi-2BpMtquNhvHXoCTQCVNO1LZqxvUJf2y77FfP-2B5UjJzbi4XVbcDbVVnMU7Aqyu7IVeFIQQ...
Effective URL: https://th-wfe-101.advancedmd.com/?lk=154693
Submission: On August 29 via manual from IN — Scanned from DE
Effective URL: https://th-wfe-101.advancedmd.com/?lk=154693
Submission: On August 29 via manual from IN — Scanned from DE
Form analysis 1 forms found in the DOM
<form _ngcontent-ng-c2524979973="" novalidate="" class="ng-untouched ng-pristine ng-invalid">
<div _ngcontent-ng-c2524979973="" fxlayout="column" fxlayoutalign="start center" fxlayoutgap="20px" class="outer-section py-14"
style="flex-direction: column; box-sizing: border-box; display: flex; place-content: center flex-start; align-items: center;">
<div _ngcontent-ng-c2524979973="" class="form-section" style="margin-bottom: 20px;"><mat-form-field _ngcontent-ng-c2524979973="" ngskiphydration=""
class="mat-form-field full-width no-margin-form-field patient-name-input ng-tns-c2794762957-0 mat-primary mat-form-field-type-mat-input mat-form-field-appearance-outline mat-form-field-can-float mat-form-field-has-label mat-form-field-hide-placeholder ng-untouched ng-pristine ng-invalid ng-star-inserted">
<div class="mat-form-field-wrapper ng-tns-c2794762957-0">
<div class="mat-form-field-flex ng-tns-c2794762957-0">
<div class="mat-form-field-outline ng-tns-c2794762957-0 ng-star-inserted">
<div class="mat-form-field-outline-start ng-tns-c2794762957-0" style="width: 5.5px;"></div>
<div class="mat-form-field-outline-gap ng-tns-c2794762957-0" style="width: 110.5px;"></div>
<div class="mat-form-field-outline-end ng-tns-c2794762957-0"></div>
</div>
<div class="mat-form-field-outline mat-form-field-outline-thick ng-tns-c2794762957-0 ng-star-inserted">
<div class="mat-form-field-outline-start ng-tns-c2794762957-0" style="width: 5.5px;"></div>
<div class="mat-form-field-outline-gap ng-tns-c2794762957-0" style="width: 110.5px;"></div>
<div class="mat-form-field-outline-end ng-tns-c2794762957-0"></div>
</div><!----><!----><!---->
<div class="mat-form-field-infix ng-tns-c2794762957-0"><input _ngcontent-ng-c2524979973="" matinput="" type="text" formcontrolname="lastname" required="" autocomplete="off" maxlength="35"
class="mat-input-element mat-form-field-autofill-control ng-tns-c2794762957-0 ng-untouched ng-pristine ng-invalid cdk-text-field-autofill-monitored" id="mat-input-0" aria-required="true"><span
class="mat-form-field-label-wrapper ng-tns-c2794762957-0"><label class="mat-form-field-label ng-tns-c2794762957-0 mat-empty mat-form-field-empty ng-star-inserted" id="mat-form-field-label-1" for="mat-input-0"
aria-owns="mat-input-0"><!----><mat-label _ngcontent-ng-c2524979973="" class="ng-tns-c2794762957-0 ng-star-inserted">Patient's Last Name</mat-label><!----><span aria-hidden="true"
class="mat-placeholder-required mat-form-field-required-marker ng-tns-c2794762957-0 ng-star-inserted"> *</span><!----></label><!----></span></div><!---->
</div><!---->
<div class="mat-form-field-subscript-wrapper ng-tns-c2794762957-0"><!---->
<div class="mat-form-field-hint-wrapper ng-tns-c2794762957-0 ng-trigger ng-trigger-transitionMessages ng-star-inserted" style="opacity: 1; transform: translateY(0%);"><!---->
<div class="mat-form-field-hint-spacer ng-tns-c2794762957-0"></div>
</div><!---->
</div>
</div>
</mat-form-field><!----><!---->
<div _ngcontent-ng-c2524979973="" class="full-width mt-small mb-medium ng-star-inserted"><amds-datepicker-mask-control _ngcontent-ng-c2524979973="" floatlabel="never" inputlabel="Patient's Birth Date" inputplaceholder="MM/DD/YYYY"
controlname="dateofbirth" isrequired="" class="patient-dob-input"><mat-form-field ngskiphydration=""
class="mat-form-field full-width no-margin-form-field ng-tns-c2794762957-1 mat-primary mat-form-field-type-mat-input mat-form-field-appearance-outline mat-form-field-can-float mat-form-field-has-label mat-form-field-hide-placeholder ng-untouched ng-pristine ng-invalid ng-star-inserted">
<div class="mat-form-field-wrapper ng-tns-c2794762957-1">
<div class="mat-form-field-flex ng-tns-c2794762957-1">
<div class="mat-form-field-outline ng-tns-c2794762957-1 ng-star-inserted">
<div class="mat-form-field-outline-start ng-tns-c2794762957-1" style="width: 5.5px;"></div>
<div class="mat-form-field-outline-gap ng-tns-c2794762957-1" style="width: 106px;"></div>
<div class="mat-form-field-outline-end ng-tns-c2794762957-1"></div>
</div>
<div class="mat-form-field-outline mat-form-field-outline-thick ng-tns-c2794762957-1 ng-star-inserted">
<div class="mat-form-field-outline-start ng-tns-c2794762957-1" style="width: 5.5px;"></div>
<div class="mat-form-field-outline-gap ng-tns-c2794762957-1" style="width: 106px;"></div>
<div class="mat-form-field-outline-end ng-tns-c2794762957-1"></div>
</div><!----><!----><!---->
<div class="mat-form-field-infix ng-tns-c2794762957-1"><input type="hidden" class="mat-datepicker-input ng-tns-c2794762957-1 ng-untouched ng-pristine ng-invalid" value="" required="" aria-haspopup="dialog" min="1752-12-31"
max="2024-08-29" data-mat-calendar="mat-datepicker-0"><input matinput="" mask="00/00/0000" autocomplete="off"
class="mat-input-element mat-form-field-autofill-control ng-tns-c2794762957-1 ng-untouched ng-pristine ng-invalid cdk-text-field-autofill-monitored" tabindex="0" placeholder="MM/DD/YYYY" required="" id="mat-input-1"
aria-required="true" data-placeholder="MM/DD/YYYY"><mat-datepicker class="ng-tns-c2794762957-1"></mat-datepicker><!----><span class="mat-form-field-label-wrapper ng-tns-c2794762957-1"><label
class="mat-form-field-label ng-tns-c2794762957-1 mat-empty mat-form-field-empty ng-star-inserted" id="mat-form-field-label-3" for="mat-input-1" aria-owns="mat-input-1"><!----><mat-label
class="ng-tns-c2794762957-1 ng-star-inserted">Patient's Birth Date</mat-label><!----><span aria-hidden="true" class="mat-placeholder-required mat-form-field-required-marker ng-tns-c2794762957-1 ng-star-inserted">
*</span><!----></label><!----></span></div>
<div class="mat-form-field-suffix ng-tns-c2794762957-1 ng-star-inserted"><mat-datepicker-toggle matsuffix="" class="mat-datepicker-toggle color-primary ng-tns-c2794762957-1" data-mat-calendar="mat-datepicker-0"><button
mat-icon-button="" type="button" mat-ripple-loader-uninitialized="" mat-ripple-loader-class-name="mat-mdc-button-ripple" class="mdc-icon-button mat-mdc-icon-button mat-unthemed mat-mdc-button-base" mat-ripple-loader-centered=""
aria-haspopup="dialog" aria-label="Open calendar" tabindex="-1"><span
class="mat-mdc-button-persistent-ripple mdc-icon-button__ripple"></span><!----><i matdatepickertoggleicon="" class="amds-icon amds-icon-appointments"></i><span class="mat-mdc-focus-indicator"></span><span
class="mat-mdc-button-touch-target"></span></button></mat-datepicker-toggle></div><!---->
</div><!---->
<div class="mat-form-field-subscript-wrapper ng-tns-c2794762957-1"><!---->
<div class="mat-form-field-hint-wrapper ng-tns-c2794762957-1 ng-trigger ng-trigger-transitionMessages ng-star-inserted" style="opacity: 1; transform: translateY(0%);"><!---->
<div class="mat-form-field-hint-spacer ng-tns-c2794762957-1"></div>
</div><!---->
</div>
</div>
</mat-form-field></amds-datepicker-mask-control></div><!----><!----><button _ngcontent-ng-c2524979973="" type="submit" mat-button="" color="primary"
class="mat-focus-indicator full-width mt-xsmall mat-button mat-button-base mat-primary ng-star-inserted"><span class="mat-button-wrapper">Confirm</span><span matripple="" class="mat-ripple mat-button-ripple"></span><span
class="mat-button-focus-overlay"></span></button><!----><!---->
</div>
<div _ngcontent-ng-c2524979973="" class="disclaimer-section base-light-gray1-bg ng-star-inserted">
<p _ngcontent-ng-c2524979973="" class="font-bold"><span _ngcontent-ng-c2524979973="" class="amds-icon amds-icon-exclamation-triangle text-dark1"></span> Important Information</p>
<div _ngcontent-ng-c2524979973="">
<p>If this is an emergency, call <strong>911</strong>.</p>
<p>Your credit card will be charged for your portion of today's visit. </p>
<p>Your telehealth provider may request an in person follow-up visit before a diagnosis can be made and care is provided. Telehealth charges still apply.</p>
<p>Your telemedicine session is private. Video sessions and payments are processed through our secure portal.</p>
</div>
</div><!----><!----><!---->
</div>
</form>Text Content
TELEHEALTH Confirm Patient Identity Patient's Last Name * Patient's Birth Date * Confirm Important Information If this is an emergency, call 911. Your credit card will be charged for your portion of today's visit. Your telehealth provider may request an in person follow-up visit before a diagnosis can be made and care is provided. Telehealth charges still apply. Your telemedicine session is private. Video sessions and payments are processed through our secure portal. Need Assistance? Call (314) 590‑3721