360smartercare.gomohealth.care
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Submitted URL: https://gcv.io/XqMdpw
Effective URL: https://360smartercare.gomohealth.care/concierge-enrollment/Victaulic/enroll/?peopleid=f14b768a99e84519a0c12a022f117c66
Submission: On March 16 via manual from US — Scanned from DE
Effective URL: https://360smartercare.gomohealth.care/concierge-enrollment/Victaulic/enroll/?peopleid=f14b768a99e84519a0c12a022f117c66
Submission: On March 16 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET https://360smartercare.gomohealth.care/
<form role="search" class="searchform fusion-search-form fusion-search-form-clean" method="get" action="https://360smartercare.gomohealth.care/">
<div class="fusion-search-form-content">
<div class="fusion-search-field search-field">
<label><span class="screen-reader-text">Search for:</span>
<input type="search" value="" name="s" class="s" placeholder="Search..." required="" aria-required="true" aria-label="Search...">
</label>
</div>
<div class="fusion-search-button search-button">
<input type="submit" class="fusion-search-submit searchsubmit" aria-label="Search" value="">
</div>
</div>
</form>POST /concierge-enrollment/Victaulic/enroll/?peopleid=f14b768a99e84519a0c12a022f117c66#gf_12
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_12" id="gform_12" action="/concierge-enrollment/Victaulic/enroll/?peopleid=f14b768a99e84519a0c12a022f117c66#gf_12">
<div class="gform_body">
<ul id="gform_fields_12" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_12_1" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_1" id="input_12_1" type="hidden" class="gform_hidden" aria-invalid="false"
value="f14b768a99e84519a0c12a022f117c66"></li>
<li id="field_12_2" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_2" id="input_12_2" type="hidden" class="gform_hidden" aria-invalid="false" value=""></li>
<li id="field_12_3" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_3" id="input_12_3" type="hidden" class="gform_hidden" aria-invalid="false"
value="https://360smartercare.gomohealth.care/concierge-enrollment/Victaulic/enroll/?peopleid=f14b768a99e84519a0c12a022f117c66"></li>
<li id="field_12_4" class="gfield gform_hidden field_sublabel_below field_description_below gfield_visibility_visible"><input name="input_4" id="input_12_4" type="hidden" class="gform_hidden" aria-invalid="false" value="https://gcv.io/"></li>
<li id="field_12_5" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">
<p>Complete the form below to customize the type of messages you receive.</p>
</li>
<li id="field_12_6" class="gfield gfield_contains_required field_sublabel_above field_description_above gfield_visibility_visible"><label class="gfield_label gfield_label_before_complex">Name<span class="gfield_required">*</span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_12_6">
<span id="input_12_6_3_container" class="name_first">
<label for="input_12_6_3">First</label>
<input type="text" name="input_6.3" id="input_12_6_3" value="" aria-label="First name" aria-required="true" aria-invalid="false">
</span>
<span id="input_12_6_6_container" class="name_last">
<label for="input_12_6_6">Last</label>
<input type="text" name="input_6.6" id="input_12_6_6" value="" aria-label="Last name" aria-required="true" aria-invalid="false">
</span>
</div>
</li>
<li id="field_12_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How would you like to receive program communications?<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_12_7">
<li class="gchoice_12_7_1">
<input name="input_7.1" type="checkbox" value="Text Message" id="choice_12_7_1">
<label for="choice_12_7_1" id="label_12_7_1">Text Message</label>
</li>
<li class="gchoice_12_7_2">
<input name="input_7.2" type="checkbox" value="Email" id="choice_12_7_2">
<label for="choice_12_7_2" id="label_12_7_2">Email</label>
</li>
</ul>
</div>
</li>
<li id="field_12_8" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_8">Mobile Phone Number<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_8" id="input_12_8" type="text" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_12_8" disabled=""></div>
<div class="gfield_description" id="gfield_description_12_8"><span style="font-style: italic;">You’ll receive up to 1-4 messages/week from the number 43386. Message and Data rates may apply according to your carrier). You may opt out of
receiving text messages at any time by texting “STOP” to 43386.</span></div>
</li>
<li id="field_12_9" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_9">Email Address<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_9" id="input_12_9" type="text" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_12_9" disabled="">
</div>
<div class="gfield_description" id="gfield_description_12_9"><span style="font-style: italic;">You’ll receive up to 1-4 messages/week via email from <a href="mailto:noreply@360smartercare.com">noreply@360smartercare.com</a>. You may
unsubscribe at any time by clicking the Unsubscribe link in the email.</span></div>
</li>
<li id="field_12_10" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible"><label class="gfield_label">I am interested in:<span class="gfield_required">*</span></label>
<div class="gfield_description" id="gfield_description_12_10">Select up to 2</div>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_12_10">
<li class="gchoice_12_10_1">
<input name="input_10.1" type="checkbox" value="Pregnancy" id="choice_12_10_1">
<label for="choice_12_10_1" id="label_12_10_1">Pregnancy</label>
</li>
<li class="gchoice_12_10_2">
<input name="input_10.2" type="checkbox" value="Post-Partum Support" id="choice_12_10_2">
<label for="choice_12_10_2" id="label_12_10_2">Post-Partum Support</label>
</li>
<li class="gchoice_12_10_3">
<input name="input_10.3" type="checkbox" value="Cardiac Care" id="choice_12_10_3">
<label for="choice_12_10_3" id="label_12_10_3">Cardiac Care</label>
</li>
<li class="gchoice_12_10_4">
<input name="input_10.4" type="checkbox" value="Mental Health Related Condition" id="choice_12_10_4">
<label for="choice_12_10_4" id="label_12_10_4">Mental Health Related Condition</label>
</li>
<li class="gchoice_12_10_5">
<input name="input_10.5" type="checkbox" value="Diabetes" id="choice_12_10_5">
<label for="choice_12_10_5" id="label_12_10_5">Diabetes</label>
</li>
<li class="gchoice_12_10_6">
<input name="input_10.6" type="checkbox" value="Substance Abuse" id="choice_12_10_6">
<label for="choice_12_10_6" id="label_12_10_6">Substance Abuse</label>
</li>
<li class="gchoice_12_10_7">
<input name="input_10.7" type="checkbox" value="Smoking Cessation" id="choice_12_10_7">
<label for="choice_12_10_7" id="label_12_10_7">Smoking Cessation</label>
</li>
<li class="gchoice_12_10_8">
<input name="input_10.8" type="checkbox" value="General Health and Wellness" id="choice_12_10_8">
<label for="choice_12_10_8" id="label_12_10_8">General Health and Wellness</label>
</li>
</ul>
</div>
</li>
<li id="field_12_11" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_11">Due Date<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_date">
<input name="input_11" id="input_12_11" type="text" value="" class="datepicker medium mdy datepicker_with_icon hasDatepicker" aria-describedby="input_12_11_date_format" disabled=""><img class="ui-datepicker-trigger"
src="/wp-content/plugins/gravityforms/images/calendar.png" alt="" title="">
<span id="input_12_11_date_format" class="screen-reader-text">Date Format: MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_12_11" class="gform_hidden" value="/wp-content/plugins/gravityforms/images/calendar.png" disabled="">
</li>
<li id="field_12_12" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_12">Child's Birth Date<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_date">
<input name="input_12" id="input_12_12" type="text" value="" class="datepicker medium mdy datepicker_with_icon hasDatepicker" aria-describedby="input_12_12_date_format" disabled=""><img class="ui-datepicker-trigger"
src="/wp-content/plugins/gravityforms/images/calendar.png" alt="" title="">
<span id="input_12_12_date_format" class="screen-reader-text">Date Format: MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_12_12" class="gform_hidden" value="/wp-content/plugins/gravityforms/images/calendar.png" disabled="">
</li>
<li id="field_12_13" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_13">Child's Name<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_12_13" type="text" value="" class="medium" aria-required="true" aria-invalid="false" disabled=""></div>
</li>
<li id="field_12_14" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Which of the following best describes your needs for
substance abuse support?<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_14">
<li class="gchoice_12_14_0"><input name="input_14" type="radio" value="I am currently abusing substances and am looking for general guidance/motivation to quit." id="choice_12_14_0" disabled=""><label for="choice_12_14_0"
id="label_12_14_0">I am currently abusing substances and am looking for general guidance/motivation to quit.</label></li>
<li class="gchoice_12_14_1"><input name="input_14" type="radio" value="I am currently sober and seeking ongoing guidance/motivation to stay sober." id="choice_12_14_1" disabled=""><label for="choice_12_14_1" id="label_12_14_1">I am
currently sober and seeking ongoing guidance/motivation to stay sober.</label></li>
</ul>
</div>
</li>
<li id="field_12_15" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Which of the following best describes your smoking cessation
interest?<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_15">
<li class="gchoice_12_15_0"><input name="input_15" type="radio" value="I want to quit asap." id="choice_12_15_0" disabled=""><label for="choice_12_15_0" id="label_12_15_0">I want to quit asap.</label></li>
<li class="gchoice_12_15_1"><input name="input_15" type="radio" value="I eventually want to quit." id="choice_12_15_1" disabled=""><label for="choice_12_15_1" id="label_12_15_1">I eventually want to quit.</label></li>
<li class="gchoice_12_15_2"><input name="input_15" type="radio" value="I have already quit." id="choice_12_15_2" disabled=""><label for="choice_12_15_2" id="label_12_15_2">I have already quit.</label></li>
</ul>
</div>
</li>
<li id="field_12_16" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Do you want to set your quit date now? We will help you prep
for the big day:<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_16">
<li class="gchoice_12_16_0"><input name="input_16" type="radio" value="Set quit date" id="choice_12_16_0" disabled=""><label for="choice_12_16_0" id="label_12_16_0">Set quit date</label></li>
<li class="gchoice_12_16_1"><input name="input_16" type="radio" value="No, not right now – remind me later" id="choice_12_16_1" disabled=""><label for="choice_12_16_1" id="label_12_16_1">No, not right now – remind me later</label></li>
</ul>
</div>
</li>
<li id="field_12_17" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_17">Set quit date:<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_date">
<input name="input_17" id="input_12_17" type="text" value="" class="datepicker medium mdy datepicker_with_icon hasDatepicker" aria-describedby="input_12_17_date_format" disabled=""><img class="ui-datepicker-trigger"
src="/wp-content/plugins/gravityforms/images/calendar.png" alt="" title="">
<span id="input_12_17_date_format" class="screen-reader-text">Date Format: MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_12_17" class="gform_hidden" value="/wp-content/plugins/gravityforms/images/calendar.png" disabled="">
</li>
<li id="field_12_18" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_18">When was your quit day? We’ll send you
supportive messages based on your quit date so you can continue a tobacco free lifestyle!<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_date">
<input name="input_18" id="input_12_18" type="text" value="" class="datepicker medium mdy datepicker_with_icon hasDatepicker" aria-describedby="input_12_18_date_format" disabled=""><img class="ui-datepicker-trigger"
src="/wp-content/plugins/gravityforms/images/calendar.png" alt="" title="">
<span id="input_12_18_date_format" class="screen-reader-text">Date Format: MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_12_18" class="gform_hidden" value="/wp-content/plugins/gravityforms/images/calendar.png" disabled="">
</li>
<li id="field_12_19" class="gfield gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" style="display: none;"><label class="gfield_label">I am interested in general health and wellness related
to:<span class="gfield_required">*</span></label>
<div class="gfield_description" id="gfield_description_12_19">Please select one of the following options</div>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_19">
<li class="gchoice_12_19_0"><input name="input_19" type="radio" value="Women's Health" id="choice_12_19_0" disabled=""><label for="choice_12_19_0" id="label_12_19_0">Women's Health</label></li>
<li class="gchoice_12_19_1"><input name="input_19" type="radio" value="Men's Health" id="choice_12_19_1" disabled=""><label for="choice_12_19_1" id="label_12_19_1">Men's Health</label></li>
</ul>
</div>
</li>
<li id="field_12_20" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">My age range is:<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_20">
<li class="gchoice_12_20_0"><input name="input_20" type="radio" value="18-29" id="choice_12_20_0" disabled=""><label for="choice_12_20_0" id="label_12_20_0">18-29</label></li>
<li class="gchoice_12_20_1"><input name="input_20" type="radio" value="30-45" id="choice_12_20_1" disabled=""><label for="choice_12_20_1" id="label_12_20_1">30-45</label></li>
<li class="gchoice_12_20_2"><input name="input_20" type="radio" value="46-50" id="choice_12_20_2" disabled=""><label for="choice_12_20_2" id="label_12_20_2">46-50</label></li>
<li class="gchoice_12_20_3"><input name="input_20" type="radio" value="60+" id="choice_12_20_3" disabled=""><label for="choice_12_20_3" id="label_12_20_3">60+</label></li>
</ul>
</div>
</li>
<li id="field_12_21" class="gfield gf_list_inline radio_btns_inline_style_one mt_20 custom_rating_style gfield_contains_required field_sublabel_below field_description_above gfield_visibility_visible" style="display: none;"><label
class="gfield_label">On a scale of 1-10, how would you rate your health mindfulness? (ex. Visiting doctor annually, staying on top of medications, making healthy choices to align with your care plan, calling your doctor when health concerns
arise, etc.)<span class="gfield_required">*</span></label>
<div class="gfield_description" id="gfield_description_12_21"><span style="color: #cd3c27;font-weight: 700;">1 - I tend to struggle with staying on top of my health.</span><span class="desc_rating_right"
style="color: #29a08a;font-weight: 700; text-align: right; display: inline; float: right;">10 - I am great at staying on top of my health!</span></div>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_21">
<li class="gchoice_12_21_0"><input name="input_21" type="radio" value="1" id="choice_12_21_0" disabled=""><label for="choice_12_21_0" id="label_12_21_0">1</label></li>
<li class="gchoice_12_21_1"><input name="input_21" type="radio" value="2" id="choice_12_21_1" disabled=""><label for="choice_12_21_1" id="label_12_21_1">2</label></li>
<li class="gchoice_12_21_2"><input name="input_21" type="radio" value="3" id="choice_12_21_2" disabled=""><label for="choice_12_21_2" id="label_12_21_2">3</label></li>
<li class="gchoice_12_21_3"><input name="input_21" type="radio" value="4" id="choice_12_21_3" disabled=""><label for="choice_12_21_3" id="label_12_21_3">4</label></li>
<li class="gchoice_12_21_4"><input name="input_21" type="radio" value="5" id="choice_12_21_4" disabled=""><label for="choice_12_21_4" id="label_12_21_4">5</label></li>
<li class="gchoice_12_21_5"><input name="input_21" type="radio" value="6" id="choice_12_21_5" disabled=""><label for="choice_12_21_5" id="label_12_21_5">6</label></li>
<li class="gchoice_12_21_6"><input name="input_21" type="radio" value="7" id="choice_12_21_6" disabled=""><label for="choice_12_21_6" id="label_12_21_6">7</label></li>
<li class="gchoice_12_21_7"><input name="input_21" type="radio" value="8" id="choice_12_21_7" disabled=""><label for="choice_12_21_7" id="label_12_21_7">8</label></li>
<li class="gchoice_12_21_8"><input name="input_21" type="radio" value="9" id="choice_12_21_8" disabled=""><label for="choice_12_21_8" id="label_12_21_8">9</label></li>
<li class="gchoice_12_21_9"><input name="input_21" type="radio" value="10" id="choice_12_21_9" disabled=""><label for="choice_12_21_9" id="label_12_21_9">10</label></li>
</ul>
</div>
</li>
<li id="field_12_22" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Do you smoke?<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_22">
<li class="gchoice_12_22_0"><input name="input_22" type="radio" value="Yes" id="choice_12_22_0" disabled=""><label for="choice_12_22_0" id="label_12_22_0">Yes</label></li>
<li class="gchoice_12_22_1"><input name="input_22" type="radio" value="No" id="choice_12_22_1" disabled=""><label for="choice_12_22_1" id="label_12_22_1">No</label></li>
</ul>
</div>
</li>
<li id="field_12_23" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Are you interested in quitting?<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_23">
<li class="gchoice_12_23_0"><input name="input_23" type="radio" value="Yes, I want to quit asap" id="choice_12_23_0" disabled=""><label for="choice_12_23_0" id="label_12_23_0">Yes, I want to quit asap</label></li>
<li class="gchoice_12_23_1"><input name="input_23" type="radio" value="I eventually want to quit, but not right now" id="choice_12_23_1" disabled=""><label for="choice_12_23_1" id="label_12_23_1">I eventually want to quit, but not right
now</label></li>
<li class="gchoice_12_23_2"><input name="input_23" type="radio" value="I am not interested in quitting" id="choice_12_23_2" disabled=""><label for="choice_12_23_2" id="label_12_23_2">I am not interested in quitting</label></li>
</ul>
</div>
</li>
<li id="field_12_24" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Motivational support is key for keeping a positive mindset
and getting on the path to a tobacco-free future. Would you like to receive a daily boost message?<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_24">
<li class="gchoice_12_24_0"><input name="input_24" type="radio" value="Yes" id="choice_12_24_0" disabled=""><label for="choice_12_24_0" id="label_12_24_0">Yes</label></li>
<li class="gchoice_12_24_1"><input name="input_24" type="radio" value="No" id="choice_12_24_1" disabled=""><label for="choice_12_24_1" id="label_12_24_1">No</label></li>
</ul>
</div>
</li>
<li id="field_12_25" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">Would you like your partner, caregiver or loved one to also
receive educational information regarding your condition?<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_12_25">
<li class="gchoice_12_25_0"><input name="input_25" type="radio" value="Yes" id="choice_12_25_0" disabled=""><label for="choice_12_25_0" id="label_12_25_0">Yes</label></li>
<li class="gchoice_12_25_1"><input name="input_25" type="radio" value="No" id="choice_12_25_1" disabled=""><label for="choice_12_25_1" id="label_12_25_1">No</label></li>
</ul>
</div>
</li>
<li id="field_12_26" class="gfield gfield_contains_required field_sublabel_above field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label gfield_label_before_complex">Caregiver's Name<span
class="gfield_required">*</span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_12_26">
<span id="input_12_26_3_container" class="name_first">
<label for="input_12_26_3">First</label>
<input type="text" name="input_26.3" id="input_12_26_3" value="" aria-label="First name" aria-required="true" aria-invalid="false" disabled="">
</span>
<span id="input_12_26_6_container" class="name_last">
<label for="input_12_26_6">Last</label>
<input type="text" name="input_26.6" id="input_12_26_6" value="" aria-label="Last name" aria-required="true" aria-invalid="false" disabled="">
</span>
</div>
</li>
<li id="field_12_27" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label">How would your caregiver like to receive program
communications?<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_12_27">
<li class="gchoice_12_27_1">
<input name="input_27.1" type="checkbox" value="Text Message" id="choice_12_27_1" disabled="">
<label for="choice_12_27_1" id="label_12_27_1">Text Message</label>
</li>
<li class="gchoice_12_27_2">
<input name="input_27.2" type="checkbox" value="Email" id="choice_12_27_2" disabled="">
<label for="choice_12_27_2" id="label_12_27_2">Email</label>
</li>
</ul>
</div>
</li>
<li id="field_12_28" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_28">Caregiver's Mobile Phone Number<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_28" id="input_12_28" type="text" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_12_28" disabled=""></div>
<div class="gfield_description" id="gfield_description_12_28"><span style="font-style: italic;">They’ll receive up to 1-4 messages/week from the number 43386. Message and Data rates may apply according to your carrier). You may opt out of
receiving text messages at any time by texting “STOP” to 43386.</span></div>
</li>
<li id="field_12_29" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" style="display: none;"><label class="gfield_label" for="input_12_29">Caregiver's Email Address<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_29" id="input_12_29" type="text" value="" class="medium" aria-required="true" aria-invalid="false" aria-describedby="gfield_description_12_29" disabled="">
</div>
<div class="gfield_description" id="gfield_description_12_29"><span style="font-style: italic;">They’ll receive up to 1-4 messages/week via email from <a href="mailto:noreply@360smartercare.com">noreply@360smartercare.com</a>. You may
unsubscribe at any time by clicking the Unsubscribe link in the email.</span></div>
</li>
<li id="field_12_31" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Terms and Conditions<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_checkbox">
<ul class="gfield_checkbox" id="input_12_31">
<li class="gchoice_12_31_1">
<input name="input_31.1" type="checkbox"
value="I agree to receive periodic text messages related to the health-related topics selected above. I understand that text and email are not considered secure technology and that the messages I receive may indicate the nature of my health condition. However, beyond the general nature of my condition, I understand that this program does not send Protected Health Information (PHI) via text. I understand that the program uses text messages from my text plan and there are no additional charges."
id="choice_12_31_1">
<label for="choice_12_31_1" id="label_12_31_1">I agree to receive periodic text messages related to the health-related topics selected above. I understand that text and email are not considered secure technology and that the messages I
receive may indicate the nature of my health condition. However, beyond the general nature of my condition, I understand that this program does not send Protected Health Information (PHI) via text. I understand that the program uses
text messages from my text plan and there are no additional charges.</label>
</li>
<li class="gchoice_12_31_2">
<input name="input_31.2" type="checkbox" value="I have read and agreed to the <a target="_blank" href="https://360smartercare.gomohealth.care/terms/">terms and conditions</a> of this program." id="choice_12_31_2">
<label for="choice_12_31_2" id="label_12_31_2">I have read and agreed to the <a target="_blank" href="https://360smartercare.gomohealth.care/terms/">terms and conditions</a> of this program.</label>
</li>
</ul>
</div>
</li>
<li id="field_12_32" class="gfield field_sublabel_below field_description_below gfield_visibility_hidden" style="display: none;"><label class="gfield_label" for="input_12_32">All selected</label>
<div class="ginput_container ginput_container_text"><input name="input_32" id="input_12_32" type="text" value="1" class="medium" aria-invalid="false" disabled=""></div>
</li>
<li id="field_12_33" class="gfield gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden"><label class="gfield_label" for="input_12_33">All Selected Boolean</label>
<div class="ginput_container ginput_container_number"><input name="input_33" id="input_12_33" type="text" value="" class="medium" readonly="readonly" aria-invalid="false"></div>
</li>
<li id="field_12_34" class="gfield field_sublabel_below field_description_below gfield_visibility_hidden"><label class="gfield_label" for="input_12_34">Current Date</label>
<div class="ginput_container ginput_container_date">
<input name="input_34" id="input_12_34" type="text" value="03/16/2022" class="datepicker medium mdy datepicker_no_icon hasDatepicker" aria-describedby="input_12_34_date_format">
<span id="input_12_34_date_format" class="screen-reader-text">Date Format: MM slash DD slash YYYY</span>
</div>
<input type="hidden" id="gforms_calendar_icon_input_12_34" class="gform_hidden" value="/wp-content/plugins/gravityforms/images/calendar.png">
</li>
<li id="field_12_35" class="gfield gfield_calculation field_sublabel_below field_description_below gfield_visibility_hidden"><label class="gfield_label" for="input_12_35">Child Age Month</label>
<div class="ginput_container ginput_container_number"><input name="input_35" id="input_12_35" type="text" value="" class="medium" readonly="readonly" aria-invalid="false"></div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_12" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_12"]){return false;} window["gf_submitting_12"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_12"]){return false;} window["gf_submitting_12"]=true; jQuery("#gform_12").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=12&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_12" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="12">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_12" value="WyJbXSIsIjI4OGJiZjIyYWI5ZDFhYjgzOTIwYTUwODNlODQ2YzBlIl0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_12" id="gform_target_page_number_12" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_12" id="gform_source_page_number_12" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
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CONCIERGE ENROLLMENT FORM
*
*
*
*
* Complete the form below to customize the type of messages you receive.
* Name*
First Last
* How would you like to receive program communications?*
* Text Message
* Email
* Mobile Phone Number*
You’ll receive up to 1-4 messages/week from the number 43386. Message and
Data rates may apply according to your carrier). You may opt out of receiving
text messages at any time by texting “STOP” to 43386.
* Email Address*
You’ll receive up to 1-4 messages/week via email from
noreply@360smartercare.com. You may unsubscribe at any time by clicking the
Unsubscribe link in the email.
* I am interested in:*
Select up to 2
* Pregnancy
* Post-Partum Support
* Cardiac Care
* Mental Health Related Condition
* Diabetes
* Substance Abuse
* Smoking Cessation
* General Health and Wellness
* Due Date*
Date Format: MM slash DD slash YYYY
* Child's Birth Date*
Date Format: MM slash DD slash YYYY
* Child's Name*
* Which of the following best describes your needs for substance abuse
support?*
* I am currently abusing substances and am looking for general
guidance/motivation to quit.
* I am currently sober and seeking ongoing guidance/motivation to stay
sober.
* Which of the following best describes your smoking cessation interest?*
* I want to quit asap.
* I eventually want to quit.
* I have already quit.
* Do you want to set your quit date now? We will help you prep for the big
day:*
* Set quit date
* No, not right now – remind me later
* Set quit date:*
Date Format: MM slash DD slash YYYY
* When was your quit day? We’ll send you supportive messages based on your quit
date so you can continue a tobacco free lifestyle!*
Date Format: MM slash DD slash YYYY
* I am interested in general health and wellness related to:*
Please select one of the following options
* Women's Health
* Men's Health
* My age range is:*
* 18-29
* 30-45
* 46-50
* 60+
* On a scale of 1-10, how would you rate your health mindfulness? (ex. Visiting
doctor annually, staying on top of medications, making healthy choices to
align with your care plan, calling your doctor when health concerns arise,
etc.)*
1 - I tend to struggle with staying on top of my health.10 - I am great at
staying on top of my health!
* 1
* 2
* 3
* 4
* 5
* 6
* 7
* 8
* 9
* 10
* Do you smoke?*
* Yes
* No
* Are you interested in quitting?*
* Yes, I want to quit asap
* I eventually want to quit, but not right now
* I am not interested in quitting
* Motivational support is key for keeping a positive mindset and getting on the
path to a tobacco-free future. Would you like to receive a daily boost
message?*
* Yes
* No
* Would you like your partner, caregiver or loved one to also receive
educational information regarding your condition?*
* Yes
* No
* Caregiver's Name*
First Last
* How would your caregiver like to receive program communications?*
* Text Message
* Email
* Caregiver's Mobile Phone Number*
They’ll receive up to 1-4 messages/week from the number 43386. Message and
Data rates may apply according to your carrier). You may opt out of receiving
text messages at any time by texting “STOP” to 43386.
* Caregiver's Email Address*
They’ll receive up to 1-4 messages/week via email from
noreply@360smartercare.com. You may unsubscribe at any time by clicking the
Unsubscribe link in the email.
* Terms and Conditions*
* I agree to receive periodic text messages related to the health-related
topics selected above. I understand that text and email are not considered
secure technology and that the messages I receive may indicate the nature
of my health condition. However, beyond the general nature of my
condition, I understand that this program does not send Protected Health
Information (PHI) via text. I understand that the program uses text
messages from my text plan and there are no additional charges.
* I have read and agreed to the terms and conditions of this program.
* All selected
* All Selected Boolean
* Current Date
Date Format: MM slash DD slash YYYY
* Child Age Month
Continued use of this site signifies your consent and agreement with these Terms
and Conditions.
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