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aeroflowurology.com Open in urlscan Pro
151.101.194.132  Public Scan

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Submitted URL: https://www.medicaid.supplies/
Effective URL: https://aeroflowurology.com/supplies-through-insurance?campaign=11515_exactdatamailer&medium=mailer&source=email
Submission: On October 26 via api from US — Scanned from ES

Form analysis 6 forms found in the DOM

POST https://aeroflowurology.com/insurance/qualify/registration/

<form autocomplete="off" enctype="multipart/form-data" action="https://aeroflowurology.com/insurance/qualify/registration/" method="post" id="insurance-form"
  data-bind="mageInit: {'validation': {}, 'Aeroflow_RealTimeEligibility/js/rte_spinner_ajax': {'formUrlRegistrationBackup': 'https://leads.aeroflowapi.org/qualify'}}" novalidate="novalidate">
  <div class="form first-step" data-bind="hidden: !showStepOne"><input name="form_key" type="hidden" value="zICfQSxwIRGZe7HY">
    <fieldset class="fieldset email">
      <legend class="legend"><span>Email</span></legend><br>
      <div class="field required"><label for="qf_email" class="label">Email</label>
        <div class="control"><input id="qf_email" name="email" data-bind="mageInit: {&quot;mage/trim-input&quot;:{}}, value: formData.email, event: { change: provider().handleFormElementChange }"
            data-validate="{&quot;required&quot;:true,&quot;validate-email&quot;:true}" data-msg-required="Email is a required field." class="input-text step-validation required-entry" aria-required="true" type="email" tabindex="0" inputmode="email"
            autocomplete="disable" data-testid="email_address" value=""></div>
      </div>
    </fieldset>
    <div class="button-container next">
      <div class="primary" tabindex="0" aria-description="Email submit button" aria-label="button"><button aria-label="Next" data-bind="disable: isLoading, click: beforeStepTwo" class="action next primary"
          data-testid="next"><span>Next</span></button></div>
      <div class="step"><span>Step 1 of 2</span></div>
    </div>
    <div id="email-exists-modal" class="email-exists-modal" data-gtm-vis-polling-id44133459_449="347">
      <div id="email-exists-modal-content" class="email-exists-modal-content" style="display: none;">
        <p>We see you already have an account. Would you like to log in, or do you have another loved one you would like to submit information for?</p>
      </div>
    </div>
  </div>
  <div class="form second-step" data-bind="hidden: !showStepTwo" style="display: none">
    <fieldset class="fieldset name">
      <legend class="legend"><!-- ko if: isPeds --><!-- /ko --><span>First Name</span></legend><br>
      <div class="field name required"><label class="label" for="qf_firstname"><!-- ko if: isPeds --><!-- /ko --><span>First Name</span></label>
        <div class="control"><input name="firstname" id="qf_firstname" title="First Name" tabindex="0" autocomplete="off" aria-required="true" data-bind="value: formData.firstname, event: { change: provider().handleFormElementChange }"
            data-validate="{required:true, 'validate-aeroflow-firstname': true}" data-msg-required="First Name is a required field." data-testid="first_name" class="input-text required-entry" type="text"></div>
      </div>
    </fieldset>
    <fieldset class="fieldset lastname">
      <legend class="legend"><!-- ko if: isPeds --><!-- /ko --><span>Last Name</span></legend><br>
      <div class="field lastname required"><label class="label" for="qf_lastname"><!-- ko if: isPeds --><!-- /ko --><span>Last Name</span></label>
        <div class="control"><input type="text" id="qf_lastname" name="lastname" title="Last Name" autocomplete="off" data-bind="value: formData.lastname, event: { change: provider().handleFormElementChange }"
            data-validate="{required:true, 'validate-aeroflow-lastname': true}" data-msg-required="Last Name is a required field." data-testid="last_name" tabindex="0" aria-required="true" class="input-text required-entry"></div>
      </div>
    </fieldset>
    <fieldset class="fieldset dob-date required">
      <legend class="legend"><!-- ko if: isPeds --><!-- /ko --><span>Date of Birth</span> <span class="tooltip"><span class="tooltip-toggle" tabindex="0" aria-labelledby="dob-date-tooltip" role="tooltip"></span> <span id="dob-date-tooltip"
            class="tooltip-content">Please provide the date of birth for the person in need of continence care supplies (yourself, your child, etc.)</span></span> </legend><br>
      <div class="field required">
        <div class="label">Date</div>
      </div>
      <div id="birth_date" class="date-container required-entry"
        data-bind="mageInit: {&quot;split-datepicker&quot;:{&quot;id&quot;:&quot;birth&quot;,&quot;targetField&quot;:&quot;dob&quot;,&quot;minYear&quot;:-120,&quot;maxYear&quot;:0,&quot;disallowPassedDates&quot;:false,&quot;monthInputId&quot;:&quot;birth_month&quot;,&quot;dayInputId&quot;:&quot;birth_day&quot;,&quot;yearInputId&quot;:&quot;birth_year&quot;,&quot;validationYearFrom&quot;:-120,&quot;validationYearTo&quot;:0,&quot;validationYear&quot;:&quot;birth_year&quot;,&quot;validationMonth&quot;:&quot;birth_month&quot;,&quot;validationDay&quot;:&quot;birth_day&quot;}}, event: { change: handleDobChange }">
        <div class="field date month required"><label for="birth_month" class="label">Month</label> <input id="birth_month" name="birth_month" data-bind="value: formData.birth_month"
            data-validate="{&quot;required&quot;:true,&quot;validate-number&quot;:true}" data-msg-required="Month is a required field." class="step-one-validation step-validation required-entry" aria-required="true" placeholder="MM" type="text"
            min="1" max="12" tabindex="0" inputmode="numeric" pattern="[0-9]*" data-testid="dob_month" value=""></div>
        <div class="field date day required"><label for="birth_day" class="label">Day</label> <input id="birth_day" name="birth_day" data-bind="value: formData.birth_day" data-validate="{&quot;required&quot;:true,&quot;validate-number&quot;:true}"
            data-msg-required="Day is a required field." class="step-one-validation step-validation required-entry" aria-required="true" placeholder="DD" type="text" min="1" max="31" tabindex="0" inputmode="numeric" pattern="[0-9]*"
            data-testid="dob_day" value=""></div>
        <div class="field date year required"><label for="birth_year" class="label">Year</label> <input id="birth_year" name="birth_year" data-bind="value: formData.birth_year"
            data-validate="{&quot;required&quot;:true,&quot;validate-number&quot;:true}" data-msg-required="Year is a required field." class="step-one-validation step-validation required-entry" aria-required="true" placeholder="YYYY" type="text"
            min="1904" max="2024" tabindex="0" inputmode="numeric" pattern="[0-9]*" data-testid="dob_year" value=""></div>
      </div>
    </fieldset>
    <fieldset class="fieldset isPeds" style="display: none"><!-- ko if: isPeds --><!-- /ko --><!-- ko ifnot: isPeds --><input type="hidden" name="is_pediatric" value="0"><!-- /ko --></fieldset>
    <fieldset class="fieldset phone">
      <legend class="legend"><span>Phone</span></legend>
      <div class="field required"><label for="phone" class="label">Phone</label>
        <div class="control"><input id="phone" maxlength="14" name="phone" data-bind="value: formData.phone, event: { change: provider().handleFormElementChange, keyup: provider().handlePhoneFormatting }"
            data-validate="{'required':true,'validate-phoneLax':true}" data-msg-required="Phone Number is a required field." data-msg-validate-phonelax="Please enter a valid phone number. Formatting happens automatically as you type."
            class="input-text required-entry" aria-required="true" type="text" tabindex="0" inputmode="numeric" data-testid="phone"></div>
      </div>
    </fieldset>
    <fieldset class="fieldset state">
      <legend class="legend"><span>State</span></legend><br>
      <div class="field state required">
        <div class="control"><label class="label" for="state"><span>State</span></label> <select name="state" id="state" class="required-entry" tabindex="0" autocomplete="off" data-bind="event: {change: handleStateChange}" aria-required="true"
            data-validate="{required:true}" data-msg-required="State is a required field." data-testid="state">
            <option value="">Select A State</option>
            <option value="1" data-code="AL">Alabama </option>
            <option value="2" data-code="AK">Alaska </option>
            <option value="4" data-code="AZ">Arizona </option>
            <option value="5" data-code="AR">Arkansas </option>
            <option value="12" data-code="CA">California </option>
            <option value="13" data-code="CO">Colorado </option>
            <option value="14" data-code="CT">Connecticut </option>
            <option value="15" data-code="DE">Delaware </option>
            <option value="16" data-code="DC">District of Columbia </option>
            <option value="18" data-code="FL">Florida </option>
            <option value="19" data-code="GA">Georgia </option>
            <option value="21" data-code="HI">Hawaii </option>
            <option value="22" data-code="ID">Idaho </option>
            <option value="23" data-code="IL">Illinois </option>
            <option value="24" data-code="IN">Indiana </option>
            <option value="25" data-code="IA">Iowa </option>
            <option value="26" data-code="KS">Kansas </option>
            <option value="27" data-code="KY">Kentucky </option>
            <option value="28" data-code="LA">Louisiana </option>
            <option value="29" data-code="ME">Maine </option>
            <option value="31" data-code="MD">Maryland </option>
            <option value="32" data-code="MA">Massachusetts </option>
            <option value="33" data-code="MI">Michigan </option>
            <option value="34" data-code="MN">Minnesota </option>
            <option value="35" data-code="MS">Mississippi </option>
            <option value="36" data-code="MO">Missouri </option>
            <option value="37" data-code="MT">Montana </option>
            <option value="38" data-code="NE">Nebraska </option>
            <option value="39" data-code="NV">Nevada </option>
            <option value="40" data-code="NH">New Hampshire </option>
            <option value="41" data-code="NJ">New Jersey </option>
            <option value="42" data-code="NM">New Mexico </option>
            <option value="43" data-code="NY">New York </option>
            <option value="44" data-code="NC">North Carolina </option>
            <option value="45" data-code="ND">North Dakota </option>
            <option value="47" data-code="OH">Ohio </option>
            <option value="48" data-code="OK">Oklahoma </option>
            <option value="49" data-code="OR">Oregon </option>
            <option value="51" data-code="PA">Pennsylvania </option>
            <option value="53" data-code="RI">Rhode Island </option>
            <option value="54" data-code="SC">South Carolina </option>
            <option value="55" data-code="SD">South Dakota </option>
            <option value="56" data-code="TN">Tennessee </option>
            <option value="57" data-code="TX">Texas </option>
            <option value="58" data-code="UT">Utah </option>
            <option value="59" data-code="VT">Vermont </option>
            <option value="61" data-code="VA">Virginia </option>
            <option value="62" data-code="WA">Washington </option>
            <option value="63" data-code="WV">West Virginia </option>
            <option value="64" data-code="WI">Wisconsin </option>
            <option value="65" data-code="WY">Wyoming </option>
          </select></div>
      </div>
    </fieldset>
    <fieldset class="fieldset zipcode">
      <legend class="legend"><span>Zip Code</span></legend>
      <div class="zipcode required"><label for="zipcode" class="label">Zip Code</label>
        <div class="control"><input id="zipcode" name="zipcode"
            data-bind="mageInit: {&quot;Aeroflow_Forms/js/limit-input-characters&quot;:{&quot;limit&quot;:5,&quot;pattern_regexp&quot;:{&quot;pattern&quot;:&quot;[^\\d]&quot;,&quot;flags&quot;:&quot;ig&quot;}},&quot;Aeroflow_Forms/js/validate-zip&quot;:true,&quot;Aeroflow_Validation/js/disable-mouse-wheel&quot;:{}}, value: formData.zipcode, event: { change: provider().handleFormElementChange }"
            data-validate="{&quot;required&quot;:true,&quot;validate-aeroflow-zipcode&quot;:true}" data-msg-required="Zip Code is a required field." class="input-text validate-zip-us required-entry" aria-required="true" type="number" min="0"
            tabindex="0" inputmode="numeric" pattern="[0-9]*" autocomplete="off" data-testid="zipcode" value=""></div>
      </div>
    </fieldset>
    <fieldset class="fieldset insurance-type">
      <div class="field" style="display: none;"><input type="hidden" name="parent_payer_pk" id="insurance_parent_payer_pk"></div>
      <legend class="legend"><!-- ko if: isPeds --><!-- /ko --><span>Insurance Provider</span> <span class="tooltip"><span class="tooltip-toggle" tabindex="0" aria-labelledby="insurance-type-tooltip"></span> <span id="insurance-type-tooltip"
            class="tooltip-content">Your insurance type is most frequently found at the top of your insurance card.</span></span></legend>
      <div class="field insurance-type required"><label class="label" for="insurance_type"><span>Insurance Provider</span></label>
        <div class="control"><select id="insurance_type" name="insurance_type" tabindex="0" autocomplete="off" aria-required="true" data-validate="{required:true}" data-msg-required="Insurance Type is a required field." data-testid="insurance_type"
            class="required-entry" data-bind="event: { change: provider().handleFormElementChange }">
            <option value="">Please Select A State First</option>
          </select></div>
      </div>
    </fieldset>
    <fieldset class="fieldset insurance_primary_provider_other" data-bind="visible: showInsuranceTypeOtherField" style="display: none;">
      <legend class="legend"><span>Name of Insurance Carrier</span></legend>
      <div class="field insurance_primary_provider_other required"><label class="label" for="insurance_primary_provider_other"><span>Name of Insurance Carrier</span></label>
        <div class="control"><input type="text" id="insurance_primary_provider_other" name="insurance_primary_provider_other" title="Name Of Insurance Carrier" tabindex="0" autocomplete="off" aria-required="true"
            data-bind="event: { change: provider().handleFormElementChange }" data-validate="{required:true, 'validate-aeroflow-insurance_primary_provider_other': true}" data-msg-required="Name Of Insurance Carrier is a required field."
            data-testid="insurance_primary_provider_other" class="input-text required-entry"></div>
      </div>
    </fieldset>
    <fieldset class="fieldset member-id">
      <legend class="legend"><span>Member ID</span> <span class="tooltip"><span class="tooltip-toggle" tabindex="0" aria-labelledby="merchant-id-tooltip"></span> <span class="tooltip-content" id="merchant-id-tooltip">Your Member ID is typically found
            on the front of your insurance card and may be listed as Member ID, Member #, Subscriber ID, Subscriber # or Policy #. This can be a combination of letters and numbers.</span> </span></legend>
      <div class="field member-id required"><label class="label" for="member_id"><span>Member ID</span></label>
        <div class="control"><input type="text" id="member_id" name="member_id" title="Member ID" tabindex="0" autocomplete="off" aria-required="true" data-bind="value: formData.member_id, event: { change: provider().handleFormElementChange }"
            data-validate="{required:true, 'validate-aeroflow-memberid': true}" data-msg-required="Member ID is a required field." data-testid="member_id" class="input-text required-entry"></div>
      </div>
    </fieldset><!-- ko if: isPeds --><!-- /ko -->
    <fieldset class="fieldset gender">
      <legend class="legend"><span>Gender</span></legend>
      <div class="field gender"><label class="label" for="gender"><span>Gender</span></label>
        <div class="control"><select name="gender" id="gender" tabindex="0" autocomplete="off" aria-required="true" data-bind="value: formData.gender, event: { change: provider().handleFormElementChange }" data-validate="{required:true}"
            data-msg-required="Gender is a required field." data-testid="gender" class="required-entry">
            <option disabled="" selected="" value="">Gender</option>
            <option value="M" data-bind="i18n: &quot;Male&quot;">Male</option>
            <option value="F" data-bind="i18n: &quot;Female&quot;">Female</option>
          </select></div>
      </div>
    </fieldset>
    <fieldset id="hdyhau_fieldset" class="fieldset how-you" style="display: block;">
      <legend class="legend"><span> How did you hear about us?</span></legend>
      <div class="field how-you"><label class="label" for="how_did_you_hear"><span> How did you hear about us?</span></label>
        <div class="control"><select name="how_did_you_hear" id="how_did_you_hear" tabindex="0" autocomplete="off" aria-required="true" data-validate="{required:true}"
            data-bind="event: { change: provider().handleFormElementChange }, value: formData.how_did_you_hear, mageInit: { &quot;ajaxHowDidYouHear&quot;: { &quot;api_url&quot;: leads_api_url, &quot;endpoint&quot;: how_did_you_hear_endpoint,&quot;hdyhFallbackOptions&quot;: hdyhFallbackOptions }}"
            data-msg-required="'How did you hear about us?' is a required field." data-testid="how_did_you_hear" class="required-entry">
            <option value="">Select</option>
            <option value="Conference or Event">Conference or Event</option>
            <option value="Doctor or Healthcare Provider">Doctor or Healthcare Provider</option>
            <option value="Facebook / Instagram">Facebook / Instagram</option>
            <option value="Friend or Family">Friend or Family</option>
            <option value="Google">Google</option>
            <option value="Influencer / Blogger">Influencer / Blogger</option>
            <option value="Insurance Company">Insurance Company</option>
            <option value="TikTok">TikTok</option>
            <option value="TV Ad (e.g. On Roku)">TV Ad (e.g. On Roku)</option>
            <option value="YouTube">YouTube</option>
            <option value="Other">Other</option>
          </select></div>
      </div>
    </fieldset>
    <fieldset class="fieldset authorize"><input type="checkbox" class="required-entry checkbox" name="authorize_checkbox" tabindex="0" aria-required="true"
        data-bind="checked: formData.authorize_checkbox, event: { change: provider().handleFormElementChange }" data-validate="{required:true}" data-testid="terms" id="authorize_checkbox"><label for="authorize_checkbox" class="authorize"><span> By
          checking this box, I provide my consent for Aeroflow Urology or Aeroflow Health to call me, even using an automatic dialer or prerecorded voice, at the number provided. Consent is not a condition of purchase of any goods or services. I also
          agree to Aeroflow Health’s dispute resolution and binding arbitration policies, its <span><a href="/website-privacy-policy">Privacy Policy</a></span>, as well as its
          <span><a href="/terms-and-conditions">Terms and Conditions.</a></span></span></label></fieldset>
    <fieldset class="fieldset authorize"><input type="checkbox" class="required-entry checkbox" name="authorize_checkbox_text" tabindex="0" aria-required="true"
        data-bind="checked: formData.authorize_checkbox_text, event: { change: provider().handleFormElementChange }" data-validate="{required:true}" data-testid="text_consent" id="authorize_checkbox_text"><label for="authorize_checkbox_text"
        class="authorize"><span> By checking this box, I provide my consent for Aeroflow Urology or Aeroflow Health to send me recurring text messages at the number provided in relation to account alerts, billing matters, and updates. Message
          frequency varies. Reply “STOP” to stop at any time. Message and data rates may apply.</span></label></fieldset> <input type="hidden" name="referral_url" value="qualify-through-insurance-supplies">
    <div class="button-container">
      <div class="primary"><button type="submit" aria-label="Submit Form" tabindex="0" class="action submit primary" data-testid="submit"><span> Submit</span></button></div>
      <div class="step"><span>Step 2 of 2</span></div><button class="uro-form-back-button" data-bind="click: handleBackAction" data-testid="back" aria-label="Go Back to Step One"><span>Go Back to Step 1</span></button>
    </div>
  </div>
</form>

POST 

<form class="form form-otp-login" method="post" id="otp-login-form" novalidate="novalidate">
  <fieldset class="fieldset login-otp step1" data-hasrequired="* Required Fields">
    <div class="field mobilenumber required">
      <div class="control"><input name="mobile_number" id="mobilenumber" type="text" class="input-text" title="Mobile Number" placeholder="Mobile Number" data-validate="{required:true}" aria-required="true" inputmode="text"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="request-otp-btn pop-bnt" name="send"><span>Send Code</span></button></div>
    </div>
  </fieldset>
  <fieldset class="fieldset login-otp step2" data-hasrequired="* Required Fields" style="display: none">
    <div class="field mobilenumber required">
      <div class="control"><input name="loginotp" id="loginotp" type="text" class="input-text" title="One Time Passcode" placeholder="One Time Passcode" data-validate="{required:true}" aria-required="true"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="resend-login-otp-btn withresend pop-bnt" name="send"><span>Resend</span></button> <button type="button" class="submit-login-otp-btn withresend pop-bnt" name="send"><span>Submit</span></button>
      </div>
    </div>
  </fieldset>
</form>

POST 

<form class="form form-password-login" method="post" id="password-login-form" novalidate="novalidate">
  <fieldset class="fieldset login-password" data-hasrequired="* Required Fields">
    <div class="field email required">
      <div class="control"><input name="emailmobile" id="emailmobilenumber" type="text" class="input-text" title="Email / Mobile Number" data-validate="{required:true}" placeholder="Email / Mobile Number" aria-required="true"></div>
    </div>
    <div class="field password required">
      <div class="control"><input name="mobpassword" type="password" autocomplete="off" class="input-text" id="logpassword" data-password-min-length="" data-password-min-character-sets="" title="Password" placeholder="Password"
          data-validate="{required:true, 'validate-customer-password':true}" aria-required="true"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="password-login-btn pop-bnt" name="send"><span>Login</span></button></div>
    </div>
  </fieldset>
</form>

POST 

<form class="form form-create-account" method="post" id="create-account-form" novalidate="novalidate">
  <fieldset class="fieldset login-password register-step1" data-hasrequired="* Required Fields">
    <div class="field firstname required">
      <div class="control"><input name="firstname" id="firstname" type="text" class="input-text" title="First Name" data-validate="{required:true}" placeholder="First Name" aria-required="true"></div>
    </div>
    <div class="field lastname required">
      <div class="control"><input name="lastname" id="lastname" type="text" class="input-text" title="Last Name" data-validate="{required:true}" placeholder="Last Name" aria-required="true"></div>
    </div>
    <div class="field mobilenumber required">
      <div class="control"><input name="mobile_number" id="regmobilenumber" type="text" class="input-text" title="Mobile Number" placeholder="Mobile Number" data-validate="{required:true}" aria-required="true" inputmode="text"></div>
    </div>
    <div class="field email required">
      <div class="control"><input name="email" id="email" type="text" class="input-text" title="Email" data-validate="{required:true, 'validate-email':true}" placeholder="Email" aria-required="true"></div>
    </div>
    <div class="field password required">
      <div class="control"><input name="mobpassword" type="password" autocomplete="off" class="input-text" id="password" data-password-min-length="" data-password-min-character-sets="" title="Password" placeholder="Password"
          data-validate="{required:true, 'validate-customer-password':true}" aria-required="true"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="create-account-btn pop-bnt"><span>Create Account</span></button></div>
    </div>
  </fieldset>
  <fieldset class="fieldset login-password register-step2" data-hasrequired="* Required Fields" style="display: none">
    <div class="field mobilenumber required">
      <div class="control"><input name="registerotp" id="registerotp" type="text" class="input-text" title="One Time Passcode" placeholder="One Time Passcode" data-validate="{required:true}" aria-required="true"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="resend-create-account-btn withresend pop-bnt" name="send"><span>Resend</span></button> <button type="button" class="submit-create-account-btn withresend pop-bnt"
          name="send"><span>Submit</span></button></div>
    </div>
  </fieldset>
</form>

POST 

<form class="form form-forget-password" method="post" id="forget-form" novalidate="novalidate">
  <fieldset class="fieldset forgot-pass-step1" data-hasrequired="* Required Fields">
    <div class="field mobilenumber required">
      <div class="control"><input name="mobile_number" id="fogmobilenumber" type="text" class="input-text" title="Mobile Number" placeholder="Mobile Number" data-validate="{required:true}" aria-required="true" inputmode="text"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="forgot-btn-req pop-bnt"><span>Send Code</span></button></div>
    </div>
  </fieldset>
  <fieldset class="fieldset forgot-pass-step2" data-hasrequired="* Required Fields" style="display: none">
    <div class="field forgototp required">
      <div class="control"><input name="forgototp" id="forgototp" type="text" class="input-text" title="OTP Number" placeholder="OTP Number" data-validate="{required:true}" aria-required="true"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="resend-forgot-otp-btn withresend pop-bnt" name="send"><span>Resend</span></button> <button type="button" class="forgot-btn-verify withresend pop-bnt"><span>Verify OTP</span></button></div>
    </div>
  </fieldset>
  <fieldset class="fieldset forgot-pass-step3" data-hasrequired="* Required Fields" style="display: none">
    <div class="field forgototp required">
      <div class="control"><input name="newpassword" id="newpassword" type="password" class="input-text" data-password-min-length="" data-password-min-character-sets="" title="Password" placeholder="Password"
          data-validate="{required:true, 'validate-customer-password':true}" aria-required="true"></div>
    </div>
    <div class="field forgototp required">
      <div class="control"><input name="confirmnewpassword" id="confirmnewpassword" type="password" class="input-text" data-password-min-length="" data-password-min-character-sets="" title="Confirm Password" placeholder="Confirm Password"
          data-validate="{required:true, 'validate-customer-password':true}" aria-required="true"></div>
    </div>
    <div class="actions-toolbar-otp">
      <div class="primary"><button type="button" class="forgot-submit-password-btn pop-bnt" name="send"><span>Submit</span></button></div>
    </div>
  </fieldset>
</form>

POST 

<form class="form form-login" method="post" data-bind="event: {submit: login }" id="login-form">
  <div class="fieldset login" data-bind="attr: {'data-hasrequired': $t('* Required Fields')}" data-hasrequired="* Required Fields">
    <div class="field email required">
      <label class="label" for="customer-auth-email"><span data-bind="i18n: 'Email Address'">Email Address</span></label>
      <div class="control">
        <input name="username" id="customer-auth-email" type="email" class="input-text" data-mage-init="{&quot;mage/trim-input&quot;:{}}" data-bind="attr: {autocomplete: autocomplete}" data-validate="{required:true, 'validate-email':true}"
          autocomplete="off">
      </div>
    </div>
    <div class="field password required">
      <label for="pass" class="label"><span data-bind="i18n: 'Password'">Password</span></label>
      <div class="control">
        <input name="password" type="password" class="input-text" id="pass" data-bind="attr: {autocomplete: autocomplete}" data-validate="{required:true}" autocomplete="off">
      </div>
    </div>
    <!-- ko foreach: getRegion('additional-login-form-fields') -->
    <!-- ko template: getTemplate() -->
    <!-- ko foreach: {data: elems, as: 'element'} --><!-- /ko -->
    <!-- /ko -->
    <!-- ko template: getTemplate() -->
    <input name="captcha_form_id" type="hidden" data-bind="value: formId,  attr: {'data-scope': dataScope}" value="user_login" data-scope="">
    <!-- ko if: (isRequired() && getIsVisible())--><!-- /ko -->
    <!-- /ko -->
    <!-- /ko -->
    <div class="actions-toolbar">
      <input name="context" type="hidden" value="checkout">
      <div class="primary">
        <button type="submit" class="action action-login secondary" name="send" id="send2">
          <span data-bind="i18n: 'Sign In'">Sign In</span>
        </button>
      </div>
      <div class="secondary">
        <a class="action" data-bind="attr: {href: forgotPasswordUrl}" href="https://aeroflowurology.com/customer/account/forgotpassword/">
                                <span data-bind="i18n: 'Forgot Your Password?'">Forgot Your Password?</span>
                            </a>
      </div>
    </div>
  </div>
</form>

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OVER 12K 5-STAR REVIEWS

reviews
4.9

(13,250)
Review us on Google
Bettylyn Deas

3 days ago
I love the product and the ppl are so very helpful and respectful
satchell bell

3 days ago
Omg..they're just wonderful, a lil bigger then expected but It will do
,comfortably fit ..it was plentiful more than I thought it would be, Thanks
Read more
Candice Boykin

3 days ago
The service is great !!! My boys pull up size fits them perfectly and they are
always delivered right on time. This moma has no complaints what's so ever. The
best thing I have ever signed my boys up on.
Read more
Sarah

5 days ago
Truly wonderful people and company. We've been receiving supplies every month
with no issue for over a year now. I reordered on a Sunday and got an email that
insurance would have to authorize this order so it may be delayed. Still, within
minutes, it was authorized and supplies were shipped. On a Sunday! I am so
impressed with how fast Aeroflow is. Everyone I've ever talked to is extremely
kind as well. Thank you Aeroflow!
Read more
Theresa Newwell

3 days ago
Love them they come like clock work never have any iss6eith them
Lavonda McNair

6 days ago
I'm Soo grateful 🥲🥲
Audrey McCorquodale

6 days ago
As a mom of 5, it's the convenience of not having to run out and get pull ups
for my son that I love, especially last minute. It's at my door AND I get
reminders when I need to reorder. So my son's medical needs are met and I have
less stress. Best part it's covered by our insurance.
Read more
Shirley Clay

9 days ago
I am so grateful for Aeroflow, sending me monthly supplies I don't know what I
would do without their help God bless you thank you
Read more
Marquita Smith Beachem

6 days ago
Love the products just received my first shipment of them
Tiffany Cooper

9 days ago
I know how the products are good and they fit and the people are very friendly
when you talk to him when you need to change something
Read more
Charles Snow

6 days ago
I like these guys the good people
Mary “Mae”

9 days ago
I want to get your bladder control pads.thank you.mj



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65 Beale Road Arden, NC 28704

Phone 1-844-276-5588

Fax 1-800-831-2454

8am - 6pm EST M-F

Copyright © 2024
Quick Links
 * Check My Eligibility
 * Resources

About Us
 * About Us
 * FAQs
 * Employment Opportunities
 * Customer Reviews

Support
 * Contact Us
 * Terms and Conditions
 * Editorial Policy
 * Returns Policy
 * Shipping Policy
 * Privacy Policy
 * Helpful Videos

Accreditation
 * 100% Secure
 * ACHC Accredited
 * America's Fastest-Growing Private Co
 * An Official Partner of MEDICAID
 * Top-rated Care 4.9 stars from Google








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