patient.modento.io Open in urlscan Pro
44.236.220.51  Public Scan

Form analysis
1 forms found in the DOM

POST https://patient.modento.io/periohealthprofessionals/forms/27756080?expires=1659371789&signature=248c1782c2892a3b02c89200ebe23ae213b6f739a9c692bcbed28ac4bee5d3f9

<form method="POST" action="https://patient.modento.io/periohealthprofessionals/forms/27756080?expires=1659371789&amp;signature=248c1782c2892a3b02c89200ebe23ae213b6f739a9c692bcbed28ac4bee5d3f9" accept-charset="UTF-8"><input name="_token"
    type="hidden">
  <div class="main-card__content main-card__content--forms-show ">
    <h4 class="main-card__title"> Please update your personal information </h4>
    <div class="main-card__description"> Great job! You have filled in all the required forms. If you need to update your information, please click below. </div>
    <div class="forms-show__content">
      <ul class="forms-show__forms-check-list">
      </ul>
      <ul x-show="showOptional" class="forms-show__forms-check-list" style="display: none;">
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_507240" value="507240">
            <span>Contact Details</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_507255" value="507255">
            <span>Update Patient Profile Photo</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_627454" value="627454">
            <span>Health History</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_507250" value="507250">
            <span>Dental Insurance Form</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_507236" value="507236">
            <span>ID/License Update</span>
          </label>
        </li>
      </ul>
      <p x-show="!showOptional"> Alternatively, you can click on "I need to update my information" to see the optional forms in case something changed recently. </p>
    </div>
  </div>
  <div class="main-card__actions">
    <button type="button" x-show="!showOptional" x-on:click.prevent="showOptional = true" class="main-card__main-action-btn waves-effect waves-light btn-large button__primary"> I need to update my information </button>
    <button x-show="showOptional" type="submit" class="main-card__main-action-btn waves-effect waves-light btn-large button__primary" style="display: none;"> Fill the selected forms </button>
  </div>
</form>

Text Content

You are using a browser that is not fully supported and not everything may work.
We recommend using Google Chrome, Apple Safari or Mozilla Firefox.

PERIO HEALTH PROFESSIONALS

3400 S Gessner Rd Suite #102, Houston
TX 77063, USA
 * tel. (713) 783 5442
 * info@periohealth.com
 * periohealth.com/?utm_source=google&utm_medium=organic&utm_campaign=gmb

PLEASE UPDATE YOUR PERSONAL INFORMATION

Great job! You have filled in all the required forms. If you need to update your
information, please click below.
 * Contact Details
 * Update Patient Profile Photo
 * Health History
 * Dental Insurance Form
 * ID/License Update

Alternatively, you can click on "I need to update my information" to see the
optional forms in case something changed recently.

I need to update my information Fill the selected forms

3400 S Gessner Rd Suite #102, Houston
TX 77063, USA
 * tel. (713) 783 5442
 * info@periohealth.com
 * periohealth.com/?utm_source=google&utm_medium=organic&utm_campaign=gmb