www.discover.availity.com Open in urlscan Pro
136.147.129.35  Public Scan

Form analysis
1 forms found in the DOM

POST

<form action="" onsubmit="return validateForm()" method="post">
  <div class="container" style="margin-top:25px;">
    <div class="row" style="padding-left: 40px;">
      <div class="col-xs-12" style="padding:0px;">
        <p>To update your email, enter a new one in the field below:</p>
      </div>
    </div>
    <div class="row">
      <div class="col-xs-3 col-xs-offset-1 col-sm-3">
        <p>EMAIL ADDRESS: <span class="required">*</span></p>
      </div>
      <div class="col-xs-9 col-sm-5">
        <input type="text" class="form-control" name="Email" id="Email" placeholder="Lesia.Ramirez@memorialhermann.org" value="Lesia.Ramirez@memorialhermann.org">
        <div class="emailErrorContainer"><label class="error hide alert alert-danger"></label></div>
      </div>
    </div>
    <div id="checkbox_container">
      <div class="row" style="padding-left: 40px;">
        <div class="col-xs-8" style="padding-left:0px;">
          <p>Availity sends emails about news, training, products and special offers. Use the check boxes below to make sure that you receive the information most important to you. </p><br>
        </div>
      </div>
      <div class="row">
        <div class="col-xs-3 col-xs-offset-1">
          <p>AVAILITY NEWS:</p>
        </div>
        <div class="col-xs-1">
          <input type="checkbox" class="" id="checkbox_name" name="Availity_News_Opt_In" value="True" checked="">
        </div>
      </div>
      <div class="row">
        <div class="col-xs-3 col-xs-offset-1">
          <p>EDUCATION:</p>
        </div>
        <div class="col-xs-1">
          <input type="checkbox" class="" id="checkbox_name" name="Education_Opt_In" value="True" checked="">
        </div>
      </div>
      <div class="row">
        <div class="col-xs-3 col-xs-offset-1">
          <p>EVENTS:</p>
        </div>
        <div class="col-xs-1">
          <input type="checkbox" class="" id="checkbox_name" name="Events_Opt_In" value="True" checked="">
        </div>
      </div>
      <div class="row">
        <div class="col-xs-3 col-xs-offset-1">
          <p>PRODUCT INFORMATION:</p>
        </div>
        <div class="col-xs-1">
          <input type="checkbox" class="" id="checkbox_name" name="Product_Information_Opt_In" value="True" checked="">
        </div>
      </div>
      <div class="row">
        <div class="col-xs-3 col-xs-offset-1">
          <p>SPECIAL OFFERS:</p>
        </div>
        <div class="col-xs-1">
          <input type="checkbox" class="" id="checkbox_name" name="Special_Offers_Opt_In" value="True" checked="">
        </div>
      </div>
      <div class="row">
        <div class="col-xs-3 col-xs-offset-1">
          <p>TRAINING:</p>
        </div>
        <div class="col-xs-1">
          <input type="checkbox" class="" id="checkbox_name" name="Training_Opt_In" value="True" checked="">
        </div>
      </div>
    </div>
    <div class="row">
      <hr>
      <div class="col-xs-3 col-xs-offset-1">
        <p>UNSUBSCRIBE FROM ALL:</p>
      </div>
      <div class="col-xs-1">
        <input type="checkbox" class="" id="Checkbox_All" name="Unsubscribe" value="True">
      </div>
    </div>
    <div class="row" style="padding-top:20px;">
      <div class="col-xs-12 text-center">
        <button class="enroll">UPDATE YOUR PREFERENCES</button>
      </div>
      <div class="col-xs-12 text-center">
        <span class="required">*</span> Indicates required.
      </div>
    </div>
  </div>
  <input type="hidden" value="Lesia.Ramirez@memorialhermann.org" name="subscriberKey">
  <input type="hidden" name="isPosted" value="true">
</form>

Text Content

EMAIL PREFERENCES

CUSTOMIZE YOUR AVAILITY EXPERIENCE

To update your email, enter a new one in the field below:

EMAIL ADDRESS: *



Availity sends emails about news, training, products and special offers. Use the
check boxes below to make sure that you receive the information most important
to you.


AVAILITY NEWS:



EDUCATION:



EVENTS:



PRODUCT INFORMATION:



SPECIAL OFFERS:



TRAINING:



--------------------------------------------------------------------------------

UNSUBSCRIBE FROM ALL:


UPDATE YOUR PREFERENCES
* Indicates required.

FOLLOW US:

 * 
 * 
 * 
 * 

© 2016 Availity , LLC | All rights reserved

 * Privacy Policy

 * Terms of Use