survey3.medallia.com Open in urlscan Pro
147.75.243.92  Public Scan

Form analysis
1 forms found in the DOM

Name: surveyform — POST /?em6tpsrrmwv5kmswvvb9

<form name="surveyform" action="/?em6tpsrrmwv5kmswvvb9" method="post"><!-- react-empty: 4 -->
  <div><!-- react-empty: 6 --><input type="hidden" name="is_embedded" id="is_embedded" value="false">
    <header><a class="layout_skipNav" href="#content">Skip to Content</a>
      <div class="layout_layoutContainer">
        <div class="layout_mainHeader layout_clearfix">
          <div class="layout_mainHeaderLeft">
            <h1 class="layout_invisibleTitle" tabindex="0" aria-label="Survey"></h1><img id="pageLogo" class="layout_logo" src="https://global.cdn.survey.medallia.com/04e3e46825ebf267e587d22453559c0f9c24e7c6" alt="Page_logo">
          </div>
          <div class="layout_mainHeaderRight"><span id="languageSelector" class="">
              <div>
                <div class="layout_notMobileScreenOnly">
                  <div class="dropdown_dropdownLabel dropdown_dropdownLabel_isInactive">Choose Language:</div>
                  <div class="dropdown_dropdownContainer ">
                    <div class="dropdown_dropdownSelector dropdown_dropdownSelector_isInactive" role="button" tabindex="0" aria-haspopup="true" aria-expanded="false" title="" aria-label="Choose Language:">
                      <div class="dropdown_dropdownTitle">English</div><i aria-hidden="true" class="medallicons_medallicons dropdown_dropdownIcon"></i>
                    </div>
                    <div role="application">
                      <ul role="menu" class="dropdown_dropdownList">
                        <li role="menuitem" tabindex="-1" class="dropdown_dropdownListItem" data-test-name="option-english">
                          <!-- react-text: 27 -->English<!-- /react-text --><i aria-hidden="true" class="medallicons_medallicons dropdown_dropdownIcon"></i></li>
                        <li role="menuitem" tabindex="-1" class="dropdown_dropdownListItem" data-test-name="option-spanish"><!-- react-text: 30 -->Spanish<!-- /react-text --></li>
                      </ul>
                    </div>
                  </div>
                </div>
                <div class="layout_mobileScreenOnly">
                  <div class="dropdown_dropdownLabel dropdown_dropdownLabel_isInactive">Choose Language:</div>
                  <div class="dropdown_dropdownContainer ">
                    <div class="dropdown_dropdownSelector dropdown_dropdownSelector_isInactive" title="" aria-haspopup="true" aria-expanded="false" role="button" tabindex="0" aria-label="Choose Language:">
                      <div class="dropdown_dropdownTitle">English</div><i aria-hidden="true" class="medallicons_medallicons dropdown_dropdownIcon"></i>
                    </div>
                  </div>
                </div>
              </div><input type="hidden" name="lang" id="activeLang" value="en">
            </span></div>
        </div>
      </div>
    </header>
    <div class="layout_layoutContainer"><input type="hidden" name="stay_main-pager" value="0"><input type="hidden" name="nodeId" value="survey3-fe4"><input type="hidden" name="ballotVer" value="12"><input type="hidden" name="currentPage"
        value="0"><input type="hidden" name="defPgrAction" value="next"><!-- react-empty: 44 --></div>
    <div role="main" id="content" class="layout_layoutContainer layout_layoutContainer_fadeInUp">
      <div class="longform_longformContainer questionBlock singleSelectQuestion">
        <fieldset>
          <legend class="question_questionTitle"><span class="validation_validationBlock validationMessage validation_requiredBlock"><i aria-hidden="true" class="medallicons_medallicons validation_validationIcon"></i><span
                class="validation_caption">Required</span></span><span class="questionCaption">Our records show that you met with our pediatrics team at&nbsp;the Banner Health Center in Gilbert on Gilbert &amp; Warner Rd on July 5, 2023. <br><br> Is
              this correct?</span></legend>
          <div class="longform_groupContainer">
            <div class="layout_answers longform_group"><!-- react-text: 55 --><!-- /react-text -->
              <ul class="group_group">
                <li class="group_optionContainer">
                  <div class="layout_answer" data-test-name="option-yes">
                    <div id="JAWS_CLICK_TARGET" class="table_table option_optionContainer table_table_hasFixedLayout">
                      <div class="row_row">
                        <div class="cell_cell option_indicatorContainer"><input type="radio" id="onf_q_bh_clinics_nps_confirm_v1_0" aria-label="Yes" class="option_input" data-mds-value="0" name="onf_q_bh_clinics_nps_confirm_v1" value="0"><span
                            class="indicatorRadio_indicatorRadioContainer option_indicator indicatorRadio"></span></div>
                        <div class="cell_cell option_captionContainer"><span aria-hidden="true" class="option_caption">Yes</span></div>
                      </div>
                    </div>
                  </div>
                </li>
                <li class="group_optionContainer">
                  <div class="layout_answer" data-test-name="option-no">
                    <div id="JAWS_CLICK_TARGET" class="table_table option_optionContainer table_table_hasFixedLayout">
                      <div class="row_row">
                        <div class="cell_cell option_indicatorContainer"><input type="radio" id="onf_q_bh_clinics_nps_confirm_v1_1" aria-label="No" class="option_input" data-mds-value="1" name="onf_q_bh_clinics_nps_confirm_v1" value="1"><span
                            class="indicatorRadio_indicatorRadioContainer option_indicator indicatorRadio"></span></div>
                        <div class="cell_cell option_captionContainer"><span aria-hidden="true" class="option_caption">No</span></div>
                      </div>
                    </div>
                  </div>
                </li>
              </ul>
            </div>
          </div>
        </fieldset>
      </div>
      <div class="htmlBlock"></div>
    </div>
    <nav class="layout_layoutContainer layout_layoutContainer_fadeIn">
      <div class="navigationButtons_navigationButtonsContainer navigationButtons_navigationButtonsContainer_hasOneButton">
        <div class="navigationButtons_pageButtonContainer"><button type="submit" class="beginButton button_button button_button_isPrimary _moveForwardButton_" id="buttonBegin" value="Begin Survey" name="forward_main-pager"><span
              class="button_buttonCaption">Begin Survey</span><i aria-hidden="true" class="medallicons_medallicons button_buttonArrowIcon"></i></button></div>
      </div>
    </nav>
    <footer class="layout_layoutContainer layout_layoutContainer_fadeIn">
      <div id="customfooter" class="customFooter">
        <div>
          <div class="layout_footer"><i class="medallicons_medallicons layout_medalliaLogo"></i>
            <div class="layout_legalLinks"><a href="http://surveysupport.medallia.com/s/" target="_blank" rel="external">Survey Support</a>
              <a href="https://www.bannerhealth.com/about/legal-notices/privacy" target="_blank" rel="external">Privacy Policy</a> <a href="http://survey.medallia.com/static/cookie-policy/index.html" target="_blank">Cookie Policy</a></div>
          </div>
        </div><!-- react-empty: 85 -->
      </div>
    </footer>
  </div>
</form>

Text Content

Skip to Content

Choose Language:
English

 * English
 * Spanish

Choose Language:
English


RequiredOur records show that you met with our pediatrics team at the Banner
Health Center in Gilbert on Gilbert & Warner Rd on July 5, 2023.

Is this correct?
 * Yes
 * No


Begin Survey

Survey Support Privacy Policy Cookie Policy