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Submitted URL: https://mdnt.io/e/fIB5e7YUdJb
Effective URL: https://patient.modento.io/randolphdentalcarenc/forms/37673914?expires=1715105323&signature=793264e8ce714722798022698aa173a...
Submission: On May 01 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://patient.modento.io/randolphdentalcarenc/forms/37673914?expires=1715105323&signature=793264e8ce714722798022698aa173acf8172c1256883d23a6aeccc246e85888&%24web_only=true&_branch_match_id=1314225174357643371&_branch_referrer=H4sIAAAAAAAAA8soKSkottLXz03JK9HLzNdP1U%2FzdDJNNY8MTfFKAgDs4tGvHQAAAA%3D%3D

<form method="POST"
  action="https://patient.modento.io/randolphdentalcarenc/forms/37673914?expires=1715105323&amp;signature=793264e8ce714722798022698aa173acf8172c1256883d23a6aeccc246e85888&amp;%24web_only=true&amp;_branch_match_id=1314225174357643371&amp;_branch_referrer=H4sIAAAAAAAAA8soKSkottLXz03JK9HLzNdP1U%2FzdDJNNY8MTfFKAgDs4tGvHQAAAA%3D%3D"
  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 "Fill out the required forms" listed below </h4>
    <div class="main-card__description">
    </div>
    <div class="forms-show__content">
      <ul class="forms-show__forms-check-list">
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids_disabled[]" id="spec_disabled_2263097" value="null" disabled="disabled" checked="">
            <span>Health History</span>
          </label>
        </li>
        <input class="form-control" id="spec_2263097" hidden="" name="form_spec_ids[]" type="number" value="2263097">
      </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_2243454" value="2243454">
            <span>Contact Details</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_2243469" value="2243469">
            <span>Update Patient Profile Photo</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_2243464" value="2243464">
            <span>Dental Insurance Form</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_2243450" value="2243450">
            <span>ID/License Update</span>
          </label>
        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_2243451" value="2243451">
            <span>Request a picture</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 x-show="!showOptional" type="submit" class="main-card__main-action-btn waves-effect waves-light btn-large button__primary"> Fill out the required forms </button>
    <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

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RANDOLPH DENTAL CARE

3515 Randolph Rd, Charlotte
NC 28211
 * tel. (704) 366-3622
 * info@randolphdentalcare.com
 * randolphdentalcare.com/

RANDOLPH DENTAL CARE

3515 Randolph Rd, Charlotte
NC 28211
 * tel. (704) 366-3622
 * info@randolphdentalcare.com
 * randolphdentalcare.com/

PLEASE "FILL OUT THE REQUIRED FORMS" LISTED BELOW


 * Health History
   

 * Contact Details
 * Update Patient Profile Photo
 * Dental Insurance Form
 * ID/License Update
 * Request a picture

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

Fill out the required forms I need to update my information Fill the selected
forms
3515 Randolph Rd, Charlotte
NC 28211
 * tel. (704) 366-3622
 * info@randolphdentalcare.com
 * randolphdentalcare.com/

Connect to our practice via the Modento mobile app and start collecting LOYALTY
POINTS now.


Terms of Service Privacy Policy

CONTACT

 * info@randolphdentalcare.com
 * tel. (704) 366-3622
 * randolphdentalcare.com/

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