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Form analysis
2 forms found in the DOM

POST /create-contact.php

<form class="row" id="contact-form" action="/create-contact.php" method="post">
  <div class="col-md-6">
    <input type="text" class="form-control" name="name" id="name" placeholder="Full name">
  </div>
  <div class="col-md-6">
    <input type="email" class="form-control" name="email" id="email" placeholder="Email address">
  </div>
  <div class="col-md-6">
    <input type="text" class="form-control" name="street" id="street" placeholder="Your street">
  </div>
  <div class="col-md-6">
    <input type="text" class="form-control" name="city" id="city" placeholder="Your City">
  </div>
  <div class="col-md-6">
    <input type="text" class="form-control" name="state" id="state" placeholder="Your State">
  </div>
  <div class="col-md-6">
    <input type="text" class="form-control" name="dob" id="dob" placeholder="Your Date of Birth">
  </div>
  <div class="col-md-12">
    <input type="text" class="form-control" name="phone_number" id="phone" placeholder="Your Phone  Number">
    <div>
      <div class="form-check">
        <input class="form-check-input" type="checkbox" value="1" name="agreement" style="width: 6%;">
        <label class="form-check-label" for="flexCheckChecked" style="display: block;margin-left: 20px;margin-bottom: 10px;"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from
          Rodriguez Health Solutions. Message frequency may vary. Reply STOP to cancel, Reply HELP for contact information. message and date rates may apply <a href="terms-conditions.html" target="_blank">Terms &amp; Conditions</a> |
          <a href="privacy-policy.html" target="_blank">Privacy Policy</a></label>
      </div>
    </div>
  </div>
  <div class="col-lg-12">
    <button type="submit" class="btn btn-primary" formtarget="_blank">Send Message <svg width="24" height="24" viewBox="0 0 24 24" fill="none" xmlns="http://www.w3.org/2000/svg">
        <path d="M22 2L11 13" stroke="#DFE3EB" stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
        <path d="M22 2L15 22L11 13L2 9L22 2Z" stroke="#DFE3EB" stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
      </svg>
    </button>
  </div>
</form>

POST /opt-contact.php

<form method="POST" action="/opt-contact.php">
  <div class="modal-body"><input type="text" class="form-control" placeholder="Phone" name="ph" required=""></div>
  <div class="modal-footer">
    <button type="button" class="btn btn-secondary closeModalButton">Close</button>
    <button type="submit" class="btn btn-primary">Submit</button>
  </div>
</form>

Text Content

RODRIGUEZ HEALTH SOLUTIONS

 * Home
 * Terms Conditions
 * Privacy Policy


HELLO, I’M DERECK RODRIGUEZ

Hello My name is Dereck Rodriguez. I am a licensed Health Advisor and I
specialize in helping Individuals, families, and small business owners with the
most affordable plans available in your state! I pride myself in helping others
in having a seamless experience while looking to make a change in health
coverage.




PROFESSIONAL SERVICES


Personalized Insurance Plans

Disscuss now
Let us help you find the most affordable and suitable health insurance plan for
your specific needs and budget.

Family Health Coverage Solutions

Disscuss now
We specialize in providing comprehensive health coverage options for families,
ensuring everyone is properly protected and cared for.

Small Business Health Packages

Disscuss now
As a small business owner, we understand the importance of cost-effective yet
reliable health insurance plans. Let us handle the search and selection process
for you.


WE'RE HERE TO HELP

I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from Rodriguez Health Solutions. Message
frequency may vary. Reply STOP to cancel, Reply HELP for contact information.
message and date rates may apply Terms & Conditions | Privacy Policy
Send Message


GET IN TOUCH

dsrodriguezinvestments@gmail.com
+18139068081




COPYRIGHT © 2024 - RODRIGUEZ HEALTH SOLUTIONS ALL RIGHTS RESERVED.

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