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POST /chackoallergy/Enhanced/Landing/Link/Lookup/cSISFK7MFUOZ2SzmbZNlzg

<form action="/chackoallergy/Enhanced/Landing/Link/Lookup/cSISFK7MFUOZ2SzmbZNlzg" method="post"><input data-val="true" data-val-required="The IsEmail field is required." id="IsEmail" name="IsEmail" type="hidden" value="True"><input data-val="true"
    data-val-required="The IsText field is required." id="IsText" name="IsText" type="hidden" value="False">
  <div class="col-sm-7 col-lg-5 center-container">
    <div class="row title-text">
      <h2 class="pay-bills-text">Pay your medical bills online.</h2>
      <p class="statement-info-text">Please enter the following information</p>
    </div>
    <div class="row">
      <div class="col-xs-10 col-sm-6 col-md-6 col-lg-6">
        <div class="form-group">
          <label class="label-dob" for="PatientDOB">Patient Date of Birth</label>
          <div id="datepicker-container">
            <div class="input-group date">
              <input class="form-control" data-val="true" data-val-date="The field Patient Date of Birth must be a date." data-val-required="Date of birth is required" id="txtPatientDob" name="PatientDOB" placeholder="mm/dd/yyyy" type="text"
                value="">
              <span class="input-group-addon ">
                <i class="fa fa-calendar"></i>
              </span>
            </div>
            <span class="field-validation-valid" data-valmsg-for="PatientDOB" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
      <div class="col-sm-4 col-md-4 col-lg-4 col-xs-8">
        <div class="form-group">
          <label class="label-zip" for="Zip">Zip Code</label>
          <input class="form-control" data-val="true" data-val-length="The field Zip Code must be a string with a minimum length of 5 and a maximum length of 10." data-val-length-max="10" data-val-length-min="5" data-val-regex="Zip code is invalid."
            data-val-regex-pattern="(^\d{5}(-\d{4})?$)|(^[ABCEGHJKLMNPRSTVXY]{1}\d{1}[A-Z]{1} *\d{1}[A-Z]{1}\d{1}$)" data-val-required="Zipcode is required" id="txtZipCode" name="Zip" type="text" value="">
          <span class="field-validation-valid" data-valmsg-for="Zip" data-valmsg-replace="true"></span>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-sm-4 col-md-3 col-lg-4">
        <button id="btnLookupContinue" class="btn btn-primary btn-continue">Continue</button>
      </div>
    </div>
  </div>
</form>

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Chacko Allergy
3333 Old Milton Parkway
Suite 520
Alpharetta, GA 30005
Phone: (678) 668 - 4688
Website: www.atlantaallergydoctor.com


PAY YOUR MEDICAL BILLS ONLINE.

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Chacko Allergy

P (678) 668 - 4688

W www.atlantaallergydoctor.com
3333 Old Milton Parkway Suite 520

Alpharetta, GA 30005

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