mybestsmile.mydentalvisit.com
Open in
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98.158.198.46
Public Scan
Submitted URL: https://url3579.messages.lhmailer.com/ss/c/9aELEovDkAdlTI1RIdkjAq98CLIpYT6LTk9VVGV3EonTYb2oSLVBAC_C5_COHxHLzoCwDulDb9CIBq8hPNBvUFcW1Ul...
Effective URL: https://mybestsmile.mydentalvisit.com/pages/schedappt?response=0feaee1c-e52d-4c47-ac18-2595b4971f5e%3Aa35414%3Am2&referralMethod=email
Submission: On September 07 via api from IE
Effective URL: https://mybestsmile.mydentalvisit.com/pages/schedappt?response=0feaee1c-e52d-4c47-ac18-2595b4971f5e%3Aa35414%3Am2&referralMethod=email
Submission: On September 07 via api from IE
Form analysis 1 forms found in the DOM
<form id="appointment-request-form" role="form" data-reactid="26">
<div data-reactid="27">
<div class="row" data-reactid="28">
<div class="form-group col-md-6" data-reactid="29"><label id="label-full-name" class="control-label" for="full-name" data-reactid="30">Patient Full Name:</label>
<div class="" id="full-name" data-reactid="31"><input type="text" required="" class="form-control" name="Patient Full Name:" data-reactid="32">
<div class="field-caption hide" data-reactid="33">Required</div>
</div>
</div>
<div class="form-group col-md-6" data-reactid="34"><label for="birthday" data-reactid="35">Patient Birth Date (mm/dd/yyyy):</label>
<div class="" id="birthday" data-reactid="36">
<div class="datefield-control" data-reactid="37">
<div data-reactid="38"><span data-reactid="39"></span>
<div class="" style="display:block;position:absolute;left:-9999px;z-index:9999 !important;" data-reactid="40">
<ul class="list-unstyled" data-reactid="41">
<li data-reactid="42">
<div class="datepicker" data-reactid="43">
<div class="datepicker-days" style="display:block;" data-reactid="44">
<table class="table-condensed" data-reactid="45">
<thead data-reactid="46">
<tr data-reactid="47">
<th class="prev" data-reactid="48"><span class="glyphicon glyphicon-chevron-left" data-reactid="49"></span></th>
<th class="switch" colspan="5" data-reactid="50"><!-- react-text: 51 -->September<!-- /react-text --><!-- react-text: 52 --> <!-- /react-text --><!-- react-text: 53 -->2021<!-- /react-text --></th>
<th class="next" data-reactid="54"><span class="glyphicon glyphicon-chevron-right" data-reactid="55"></span></th>
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<tr data-reactid="56">
<th class="dow" data-reactid="57">Su</th>
<th class="dow" data-reactid="58">Mo</th>
<th class="dow" data-reactid="59">Tu</th>
<th class="dow" data-reactid="60">We</th>
<th class="dow" data-reactid="61">Th</th>
<th class="dow" data-reactid="62">Fr</th>
<th class="dow" data-reactid="63">Sa</th>
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</thead>
<tbody data-reactid="64">
<tr data-reactid="65">
<td class="day old" data-reactid="66">29</td>
<td class="day old" data-reactid="67">30</td>
<td class="day old" data-reactid="68">31</td>
<td class="day" data-reactid="69">1</td>
<td class="day" data-reactid="70">2</td>
<td class="day" data-reactid="71">3</td>
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<tr data-reactid="73">
<td class="day" data-reactid="74">5</td>
<td class="day" data-reactid="75">6</td>
<td class="day active today" data-reactid="76">7</td>
<td class="day" data-reactid="77">8</td>
<td class="day" data-reactid="78">9</td>
<td class="day" data-reactid="79">10</td>
<td class="day" data-reactid="80">11</td>
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<tr data-reactid="81">
<td class="day" data-reactid="82">12</td>
<td class="day" data-reactid="83">13</td>
<td class="day" data-reactid="84">14</td>
<td class="day" data-reactid="85">15</td>
<td class="day" data-reactid="86">16</td>
<td class="day" data-reactid="87">17</td>
<td class="day" data-reactid="88">18</td>
</tr>
<tr data-reactid="89">
<td class="day" data-reactid="90">19</td>
<td class="day" data-reactid="91">20</td>
<td class="day" data-reactid="92">21</td>
<td class="day" data-reactid="93">22</td>
<td class="day" data-reactid="94">23</td>
<td class="day" data-reactid="95">24</td>
<td class="day" data-reactid="96">25</td>
</tr>
<tr data-reactid="97">
<td class="day" data-reactid="98">26</td>
<td class="day" data-reactid="99">27</td>
<td class="day" data-reactid="100">28</td>
<td class="day" data-reactid="101">29</td>
<td class="day" data-reactid="102">30</td>
<td class="day new" data-reactid="103">1</td>
<td class="day new" data-reactid="104">2</td>
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<tr data-reactid="105">
<td class="day new" data-reactid="106">3</td>
<td class="day new" data-reactid="107">4</td>
<td class="day new" data-reactid="108">5</td>
<td class="day new" data-reactid="109">6</td>
<td class="day new" data-reactid="110">7</td>
<td class="day new" data-reactid="111">8</td>
<td class="day new" data-reactid="112">9</td>
</tr>
</tbody>
</table>
</div>
</div>
</li>
</ul>
</div>
<div class="input-group date " data-reactid="113"><input type="tel" class="form-control" value="" name="Patient Birth Date (mm/dd/yyyy):" placeholder="mm/dd/yyyy" required="" data-reactid="114"><span class="input-group-addon"
data-reactid="115"><span class="glyphicon glyphicon-calendar" data-reactid="116"></span></span></div>
</div>
</div>
<div class="field-caption hide" data-reactid="117"></div>
</div>
</div>
</div>
<div data-reactid="118">
<div class="row" data-reactid="119">
<div class="form-group col-md-6" data-reactid="120">
<div data-reactid="121"><label for="email-or-phone-number" data-reactid="122">Email or Phone Number:</label>
<div class="" id="email-or-phone-number" data-reactid="123"><input type="text" required="" class="form-control" name="Email or Phone Number:" data-reactid="124">
<div class="field-caption hide" data-reactid="125">Required</div>
</div>
</div>
</div>
<div class="form-group col-md-6" data-reactid="126"><label for="how-soon" data-reactid="127">If flexible, please choose a date range:</label>
<div class="" id="how-soon" data-reactid="128">
<div class="styled-select" data-reactid="129"><select class="form-control" required="" name="If flexible, please choose a date range:" data-reactid="130">
<option hidden="" value="" data-reactid="131">Select...</option>
<option value="Soonest Available" data-reactid="132">Soonest Available</option>
<option value="This Week" data-reactid="133">This Week</option>
<option value="This Month" data-reactid="134">This Month</option>
<option value="Doesn't Matter" data-reactid="135">Doesn't Matter</option>
</select></div>
<div class="field-caption hide" data-reactid="136">Required</div>
</div>
</div>
</div>
<div class="row" data-reactid="137">
<div class="form-group col-md-6" data-reactid="138"><label for="preferred-time" data-reactid="139">Preferred Time:</label><input type="text" class="form-control" id="preferred-time" placeholder="Optional" name="Preferred Time:"
data-reactid="140"></div>
<div class="form-group col-md-6" data-reactid="141"><label for="preferred-day" data-reactid="142">Preferred Day:</label><input type="text" class="form-control" id="preferred-day" placeholder="Optional" name="Preferred Day:"
data-reactid="143"></div>
</div>
</div>
<div class="row" data-reactid="144">
<div class="form-group col-md-12" data-reactid="145"><label for="considerations" data-reactid="146">Do you have any special considerations?</label><textarea class="form-control" rows="3" id="considerations" placeholder="Optional"
name="Do you have any special considerations?" data-reactid="147"></textarea></div>
</div>
</div>
<div class="row" data-reactid="148">
<div class="col-md-2 col-md-offset-10 col-xs-12" data-reactid="149"><button type="submit" class="btn btn-primary col-xs-12 pull-right" disabled="" data-reactid="150">Submit</button></div>
</div>
</form>Text Content
MY BEST SMILE We're experiencing issues with our servers. Please try submitting the form again. If the issue persists, please call our office at (724) 779-7645. APPOINTMENT REQUEST -------------------------------------------------------------------------------- Please answer the questions below. We will do our best to schedule an appointment on your requested date and time. A confirmation email or phone call will follow with your selected time. Patient Full Name: Required Patient Birth Date (mm/dd/yyyy): * September 2021SuMoTuWeThFrSa293031123456789101112131415161718192021222324252627282930123456789 Email or Phone Number: Required If flexible, please choose a date range: Select...Soonest AvailableThis WeekThis MonthDoesn't Matter Required Preferred Time: Preferred Day: Do you have any special considerations? Submit