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navigation-equilibre-ia.ca Open in urlscan Pro
3.97.164.77  Public Scan

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Submitted URL: http://navigation-equilibre-ia.ca/
Effective URL: https://navigation-equilibre-ia.ca/
Submission: On November 01 via api from DE — Scanned from CA

Form analysis 1 forms found in the DOM

<form class="">
  <div class="sc-dTsoBL mx-0 VimHk row">
    <fieldset class="sc-RmnOB fGBKjm" aria-describedby="help-note">
      <legend aria-label="New User Registration"></legend>
      <div class="sc-jPPmml px-1 jCZyiS row">
        <div class="sc-dNoQZL px-2 mx-1 cuKkNN"><span class="sc-gjAXCV bGfaZz" id="help-note">* All fields required and must match policy information</span></div>
        <div class="sc-bIKvTM px-2 mx-1 cdGDWa col">
          <div class="input-group"><label for="first_name" class=""><span class="unselectable sc-eQGPmX ixwqQs"><span class="sc-dAOnuy eQCQwt">*</span><span class="sc-dXLFzO KAeva">First Name</span></span></label>
            <div class="sc-dOkuiw dkKghI"><input class="sc-cnTzU iCdZKU" aria-required="true" type="text" id="first_name" placeholder=""></div>
          </div>
        </div>
        <div class="sc-bIKvTM px-2 mx-1 cdGDWa col">
          <div class="input-group"><label for="last_name" class=""><span class="unselectable sc-eQGPmX ixwqQs"><span class="sc-dAOnuy eQCQwt">*</span><span class="sc-dXLFzO KAeva">Last Name</span></span></label>
            <div class="sc-dOkuiw dkKghI"><input class="sc-cnTzU iCdZKU" aria-required="true" type="text" id="last_name" placeholder=""></div>
          </div>
        </div>
        <div class="sc-bIKvTM px-2 mx-1 lmHQbY col">
          <div class="input-group"><label for="email" class=""><span class="unselectable sc-eQGPmX ixwqQs"><span class="sc-dAOnuy eQCQwt">*</span><span class="sc-dXLFzO KAeva">Email</span></span></label>
            <div class="sc-dOkuiw dkKghI"><input class="sc-cnTzU iCdZKU" aria-required="true" type="text" id="email" placeholder=""></div>
          </div>
        </div>
        <div class="sc-bIKvTM px-2 mx-1 lmHQbY col">
          <div class="input-group"><label for="password" class=""><span class="unselectable sc-eQGPmX ixwqQs"><span class="sc-dAOnuy eQCQwt">*</span><span class="sc-dXLFzO KAeva">Password</span>(must be at least 6 characters)</span></label>
            <div class="sc-dOkuiw dkKghI"><input class="sc-cnTzU egXucK" aria-required="true" type="password" id="password" placeholder=""><button type="button" aria-label="Show Password"
                class="sc-jGFFOr position-absolute d-flex align-items-center justify-content-center p-0 iYRpbE btn btn-white"><span class="isvg loaded sc-hZeNU flex-column align-self-center fkFONs"><!--?xml version="1.0"?-->
                  <svg xmlns="http://www.w3.org/2000/svg" width="20" height="19" viewBox="0 0 18 12">
                    <g fill="none" fill-rule="evenodd">
                      <path d="M0-3h18v18H0z"></path>
                      <path fill="#9E9E9E" fill-opacity=".5"
                        d="M9 .375C5.25.375 2.047 2.707.75 6c1.297 3.293 4.5 5.625 8.25 5.625S15.953 9.293 17.25 6C15.953 2.707 12.75.375 9 .375zM9 9.75C6.93 9.75 5.25 8.07 5.25 6c0-2.07 1.68-3.75 3.75-3.75 2.07 0 3.75 1.68 3.75 3.75 0 2.07-1.68 3.75-3.75 3.75zm0-6A2.247 2.247 0 0 0 6.75 6 2.247 2.247 0 0 0 9 8.25 2.247 2.247 0 0 0 11.25 6 2.247 2.247 0 0 0 9 3.75z">
                      </path>
                    </g>
                  </svg>
                </span></button></div>
          </div>
        </div>
        <div class="sc-bIKvTM px-2 mx-1 lmHQbY col">
          <div class="input-group"><label for="group_code" class=""><span class="unselectable sc-eQGPmX ixwqQs"><span class="sc-dAOnuy eQCQwt">*</span><span class="sc-dXLFzO KAeva">Group Code</span></span></label>
            <div class="sc-dOkuiw dkKghI"><input class="sc-cnTzU iCdZKU" aria-required="true" type="text" id="group_code" placeholder=""></div>
          </div>
        </div>
      </div>
    </fieldset><button type="submit" id="register-button" class="sc-btewqU font-weight-bold jkOHpB btn btn-secondary btn-block">SIGN UP</button>
  </div>
</form>

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WELCOME TO YOUR WELL-BALANCED™ HEALTH NAVIGATION PLATFORM.

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*Group Code

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