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Submitted URL: https://mdnt.io/e/OD2wOiSNrCb
Effective URL: https://patient.modento.io/kaleka-dental/forms/33290574?expires=1693235691&signature=37e05a4e145a870eec204becf10a5017efa20c...
Submission: On August 21 via manual from US — Scanned from DE
Effective URL: https://patient.modento.io/kaleka-dental/forms/33290574?expires=1693235691&signature=37e05a4e145a870eec204becf10a5017efa20c...
Submission: On August 21 via manual from US — Scanned from DE
Form analysis
1 forms found in the DOMPOST https://patient.modento.io/kaleka-dental/forms/33290574?expires=1693235691&signature=37e05a4e145a870eec204becf10a5017efa20cf1ca15ccbbd515970a8552de44&%24web_only=true&_branch_match_id=1222199481850370257&_branch_referrer=H4sIAAAAAAAAA8soKSkottLXz03JK9HLzNdP1fd3MSr3zwz2K3JOAgCqfW1lHQAAAA%3D%3D
<form method="POST"
action="https://patient.modento.io/kaleka-dental/forms/33290574?expires=1693235691&signature=37e05a4e145a870eec204becf10a5017efa20cf1ca15ccbbd515970a8552de44&%24web_only=true&_branch_match_id=1222199481850370257&_branch_referrer=H4sIAAAAAAAAA8soKSkottLXz03JK9HLzNdP1fd3MSr3zwz2K3JOAgCqfW1lHQAAAA%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_1861467" value="null" disabled="disabled" checked="">
<span>Health History</span>
</label>
</li>
<input class="form-control" id="spec_1861467" hidden="" name="form_spec_ids[]" type="number" value="1861467">
<li>
<label>
<input type="checkbox" class="filled-in" name="form_spec_ids_disabled[]" id="spec_disabled_2877602" value="null" disabled="disabled" checked="">
<span>COVID-19 Questionnaire</span>
</label>
</li>
<input class="form-control" id="spec_2877602" hidden="" name="form_spec_ids[]" type="number" value="2877602">
</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_748163" value="748163">
<span>Contact Details</span>
</label>
</li>
<li>
<label>
<input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_748178" value="748178">
<span>Update Patient Profile Photo</span>
</label>
</li>
<li>
<label>
<input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_748159" value="748159">
<span>ID/License Update</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>
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</form>
Text Content
You are using a browser that is not fully supported and not everything may work. We recommend using Google Chrome, Apple Safari or Mozilla Firefox. KALEKA DENTAL 455 Main St, El Segundo CA 90245 * tel. (310) 322 9476 * info@kalekadental.com * www.kalekadental.com/ KALEKA DENTAL 455 Main St, El Segundo CA 90245 * tel. (310) 322 9476 * info@kalekadental.com * www.kalekadental.com/ PLEASE "FILL OUT THE REQUIRED FORMS" LISTED BELOW * Health History * COVID-19 Questionnaire * Contact Details * Update Patient Profile Photo * ID/License Update 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 455 Main St, El Segundo CA 90245 * tel. (310) 322 9476 * info@kalekadental.com * www.kalekadental.com/ Connect to our practice via the Modento mobile app and start collecting LOYALTY POINTS now. Terms of Service Privacy Policy CONTACT * info@kalekadental.com * tel. (310) 322 9476 * www.kalekadental.com/ © Dental Intelligence Inc. 2012-2023