signup.sidelinesurgeons.com Open in urlscan Pro
2606:4700:3031::ac43:c39d Public Scan

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URL:
https://signup.sidelinesurgeons.com/
Submission: On June 12 via api (June 12th 2024, 2:19:50 pm UTC) from US — Scanned from DE

Form analysis
1 forms found in the DOM

POST https://signup.sidelinesurgeons.com/

<form class="af-form acf-form" method="POST" action="https://signup.sidelinesurgeons.com/" id="form_physician_sign_up" data-key="form_physician_sign_up">
  <div class="af-fields acf-fields acf-form-fields -top">
    <div id="acf-form-data" class="acf-hidden">
      <input type="hidden" id="_acf_screen" name="_acf_screen" value="acf_form"><input type="hidden" id="_acf_post_id" name="_acf_post_id" value="0"><input type="hidden" id="_acf_validation" name="_acf_validation" value="1"><input type="hidden"
        id="_acf_form" name="_acf_form" value="0"><input type="hidden" id="_acf_nonce" name="_acf_nonce" value="8057dd6f84"><input type="hidden" id="_acf_changed" name="_acf_changed" value="0">
    </div>
    <div class="acf-hidden"><input type="hidden" name="_acfnonce" value="16cca0f324"><input type="hidden" name="nonce" value="16cca0f324"><input type="hidden" name="af_form" value="form_physician_sign_up"><input type="hidden" name="af_form_args"
        value="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"><input
        type="hidden" name="_acf_form"
        value="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"><input
        type="hidden" name="af_form_nonce" value="304377612e"><label for="af_email_for_non_humans_form_physician_sign_up" aria-hidden="true">Email for non-humans</label><input type="text" name="email_for_non_humans"
        id="af_email_for_non_humans_form_physician_sign_up" tabindex="-1" autocomplete="off"><input type="hidden" name="af_origin_url" value="https://signup.sidelinesurgeons.com/"></div>
    <div class="af-field af-field-type-select af-field-occupation acf-field acf-field-select acf-field-6620fba1ada5e af-field-required" data-name="occupation" data-key="field_6620fba1ada5e" data-type="select">
      <div class="af-label acf-label"><label for="acf-field_6620fba1ada5e">Occupation <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input"><select id="acf-field_6620fba1ada5e" class="" name="acf[field_6620fba1ada5e]" data-ui="0" data-ajax="0" data-multiple="0" data-placeholder="Select" data-allow_null="0">
          <option value="SELECT OCCUPATION">SELECT OCCUPATION</option>
          <option value="AGENT">AGENT</option>
          <option value="ASSOCIATIONS">ASSOCIATIONS</option>
          <option value="ACADEMY">ACADEMY</option>
          <option value="ELITE ATHLETE">ELITE ATHLETE</option>
        </select></div>
    </div>
    <div class="af-field af-field-type-text af-field-name acf-field acf-field-text acf-field-6616c195a7d4f af-field-required" data-name="name" data-key="field_6616c195a7d4f" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c195a7d4f">Name <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c195a7d4f" name="acf[field_6616c195a7d4f]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-email af-field-email acf-field acf-field-email acf-field-66687878b494f af-field-required" data-name="email" data-key="field_66687878b494f" data-type="email">
      <div class="af-label acf-label"><label for="acf-field_66687878b494f">Email <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="email" id="acf-field_66687878b494f" name="acf[field_66687878b494f]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-phone acf-field acf-field-text acf-field-6616c195a7d5c af-field-required" data-name="phone" data-key="field_6616c195a7d5c" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c195a7d5c">Office/primary phone <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c195a7d5c" name="acf[field_6616c195a7d5c]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-cell-phone acf-field acf-field-text acf-field-6616c195a7d60 af-field-required" data-name="cell_phone" data-key="field_6616c195a7d60" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c195a7d60">Cell phone number <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c195a7d60" name="acf[field_6616c195a7d60]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-other-contact-number acf-field acf-field-text acf-field-6616c195a7d69" data-name="other_contact_number" data-key="field_6616c195a7d69" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c195a7d69">Other contact number</label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c195a7d69" name="acf[field_6616c195a7d69]"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-address acf-field acf-field-text acf-field-6616c203b399b af-field-required" data-name="address" data-key="field_6616c203b399b" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c203b399b">Address <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c203b399b" name="acf[field_6616c203b399b]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-billing-address acf-field acf-field-text acf-field-6616c214b399c af-field-required" data-name="billing_address" data-key="field_6616c214b399c" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c214b399c">Billing Address <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c214b399c" name="acf[field_6616c214b399c]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-city acf-field acf-field-text acf-field-6616c21fb399d af-field-required" data-name="city" data-key="field_6616c21fb399d" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c21fb399d">City <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c21fb399d" name="acf[field_6616c21fb399d]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-state acf-field acf-field-text acf-field-6616c234b399f af-field-required" data-name="state" data-key="field_6616c234b399f" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c234b399f">State <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c234b399f" name="acf[field_6616c234b399f]" required="required"></div>
      </div>
    </div>
    <div class="af-field af-field-type-text af-field-zip-code acf-field acf-field-text acf-field-6616c229b399e af-field-required" data-name="zip_code" data-key="field_6616c229b399e" data-type="text">
      <div class="af-label acf-label"><label for="acf-field_6616c229b399e">Zip Code <span class="acf-required">*</span></label></div>
      <div class="af-input acf-input">
        <div class="acf-input-wrap"><input type="text" id="acf-field_6616c229b399e" name="acf[field_6616c229b399e]" required="required"></div>
      </div>
    </div>
    <div class="af-submit acf-form-submit"><button type="submit" class="acf-button af-submit-button">SIGN UP</button><span class="acf-spinner af-spinner"></span></div>
  </div>
</form>

Text Content

Skip to content
 * Benefits /
 * Areas of Expertise /
 * About /
   Physicians

 * Sign up


Sign up
Benefits
Areas of Expertise

About

 * Physicians

620.728.9517
Stacy.case@sidelinesurgeons.com
P.O. Box 471451
Charlotte, NC 28247
USA





Stay up to date

 * 
 * 
 * 

 * Benefits /
 * Areas of Expertise /
 * About /
   Physicians

 * Sign up


Sign up
Benefits
Areas of Expertise

About

 * Physicians

620.728.9517
Stacy.case@sidelinesurgeons.com
P.O. Box 471451
Charlotte, NC 28247
USA





Stay up to date

 * 
 * 
 * 


SIGN UP

Fields marked with an * are required.

Email for non-humans
Occupation *
SELECT OCCUPATIONAGENTASSOCIATIONSACADEMYELITE ATHLETE
Name *

Email *

Office/primary phone *

Cell phone number *

Other contact number

Address *

Billing Address *

City *

State *

Zip Code *

SIGN UP
620.728.9517
Stacy.case@sidelinesurgeons.com
P.O. Box 471451
Charlotte, NC 28247
USA




 * BENEFITS
 * PHYSICIANS
 * ABOUT

STAY UP TO DATE

 * 
 * 
 * 

Sign up

signup.sidelinesurgeons.com Open in urlscan Pro 2606:4700:3031::ac43:c39d Public Scan

Form analysis 1 forms found in the DOM

POST https://signup.sidelinesurgeons.com/

Text Content

signup.sidelinesurgeons.com Open in urlscan Pro
2606:4700:3031::ac43:c39d Public Scan

Form analysis
1 forms found in the DOM