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Form analysis
2 forms found in the DOM

POST /create-contact.php

<form id="contact-form" class="contact__form" method="post" action="/create-contact.php">
  <input type="text" id="name" name="name" class="form-control font-weight-normal mb-4 px-2" placeholder="Full name" style="font-weight: 600;">
  <input type="email" id="email" name="email" class="form-control font-weight-normal mb-4 px-2" placeholder="Email address" style="font-weight: 600;">
  <input type="text" id="street" name="street" class="form-control font-weight-normal mb-4 px-2" placeholder="Your street" style="font-weight: 600;">
  <input type="text" id="city" name="city" class="form-control font-weight-normal mb-4 px-2" placeholder="Your City" style="font-weight: 600;">
  <input type="text" id="state" name="state" class="form-control font-weight-normal mb-4 px-2" placeholder="Your State" style="font-weight: 600;">
  <input type="text" id="dob" name="dob" class="form-control font-weight-normal mb-4 px-2" placeholder="Your Date of Birth" style="font-weight: 600;">
  <input type="text" id="phone" name="phone_number" class="form-control font-weight-normal mb-4 px-2" placeholder="Phone number" style="font-weight: 600;">
  <div>
    <input type="checkbox" name="agreement" value="1"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from ZACH HEALTH. Message frequency may vary. Reply STOP to cancel, Reply HELP
    for contact information. message and date rates may apply <a href="terms-conditions.html">Terms &amp; Conditions</a> | <a href="privacy-policy.html">Privacy Policy</a>
  </div>
  <div class="text-center">
    <button class="btn btn-primary mt-3 rounded" type="submit">Send</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

ZACH HEALTH
 * Home
 * Terms Conditions
 * Privacy Policy


ZACH HEALTH


ZACHARY BLUMER

I'm a licensed health insurance advisor helping families and individuals find
health coverage that meets their unique needs, offering affordable,
comprehensive options for long-term security and peace of mind.




PROFESSIONAL SERVICES

CUSTOMIZED HEALTH COVERAGE

Let us help you find the perfect health insurance plan for your family or
individual needs. Our licensed advisors will work with you to create a
comprehensive and affordable option that provides long-term security and peace
of mind.

PERSONALIZED INSURANCE RECOMMENDATIONS

Navigating the world of health insurance can be overwhelming. That's why we're
here to provide personalized recommendations based on your unique situation.
Trust our expertise to guide you towards the best coverage for your needs.

COMPREHENSIVE LONG-TERM PROTECTION

At ZACH HEALTH, we understand the importance of having reliable health coverage
for years to come. We offer comprehensive options that not only meet your
current needs, but also provide long-term protection and stability for you and
your loved ones.


TALK TO US


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


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