mainwebsite-cucseuabc3btdvdv.canadacentral-01.azurewebsites.net
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20.48.204.1
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URL:
https://mainwebsite-cucseuabc3btdvdv.canadacentral-01.azurewebsites.net/
Submission: On November 26 via manual from US — Scanned from CA
Submission: On November 26 via manual from US — Scanned from CA
Form analysis 3 forms found in the DOM
POST contact_form_data.php
<form action="contact_form_data.php" method="post">
<fieldset class="fieldset contactform__fieldset">
<legend class="legend contactform__legend"></legend>
<div class="form-body contactform__form-body">
<div class="form-group contactform__form-group">
<label class="label label--email contactform__label" for="page-zones__main-widgets__64b8333956519-widgets__64b833395bcd9-zones__64b833395f3e0-widgets__64b9382c036e1__input--email">Your email address</label>
<input class="input input--email input--single-line contactform__input js-email-input" id="page-zones__main-widgets__64b8333956519-widgets__64b833395bcd9-zones__64b833395f3e0-widgets__64b9382c036e1__input--email" name="email"
placeholder="name@email.com" type="email" autocomplete="email" spellcheck="false" aria-required="true" required="">
</div>
<div class="form-group contactform__form-group">
<label class="label label--message contactform__label" for="page-zones__main-widgets__64b8333956519-widgets__64b833395bcd9-zones__64b833395f3e0-widgets__64b9382c036e1__textarea--message">Message</label>
<textarea class="textarea textarea--message contactform__textarea js-message-input" id="page-zones__main-widgets__64b8333956519-widgets__64b833395bcd9-zones__64b833395f3e0-widgets__64b9382c036e1__textarea--message" name="message"
aria-required="true" required=""></textarea>
</div>
<!-- reCAPTCHA widget -->
<!-- <div class="g-recaptcha" data-sitekey="6Ldfxr0pAAAAAFzy5iz3D90fiX2DROREg-JhwPlk" data-callback="recaptchaCallback" required></div> -->
<div class="form-group contactform__form-group">
<button class="button button--submit contactform__button js-button" name="contact_form" type="submit" value="Submit">
<span class="loading-spinner js-loading-spinner hidden"></span>
<span class="js-submit-button-text">Send</span>
</button>
</div>
</div>
</fieldset>
</form>POST subscribe_form_data.php
<form action="subscribe_form_data.php" method="post" class="form">
<fieldset class="fieldset advancedcontactform__fieldset">
<legend class="legend advancedcontactform__legend"></legend>
<div class="form-body advancedcontactform__form-body">
<div class="form-group advancedcontactform__form-group" style="margin-bottom: 0;">
<label class="label label--email advancedcontactform__label" for="page-zones__main-widgets__6478c9ea752b0-widgets__64c200bce4c1e-email__input--email">Subscribe to our Newsletter</label>
<input type="email" required="" class="" placeholder="Type your email address" name="email" autocomplete="email" spellcheck="false" aria-required="true">
</div>
<!-- reCAPTCHA widget -->
<!-- <div class="g-recaptcha" data-sitekey="6Ldfxr0pAAAAAFzy5iz3D90fiX2DROREg-JhwPlk" data-callback="recaptchaCallback" required></div> -->
<div class="form-group advancedcontactform__form-group" style="margin-top: 10px;">
<button class="button button--submit js-button advancedcontactform__button" type="submit" name="subscribe">Subscribe!</button>
</div>
</div>
</fieldset>
</form>POST insert_form_data.php
<form action="insert_form_data.php" method="POST">
<label for="location"><span id="nameRequired" class="required-symbol">*</span>Name</label>
<input type="text" id="name" name="name" placeholder=" Enter Name" required=""><br>
<label for="location"><span id="nameRequired" class="required-symbol">*</span>Location:</label><br>
<input type="text" id="location" name="location" placeholder=" Enter Location" required=""><br>
<label for="age"><span id="nameRequired" class="required-symbol">*</span>Age Bracket:</label><br>
<select id="age" name="age" required="">
<option value="">Please Select Age</option>
<option value="< 25 years"> < 25 years</option>
<option value="25-35">25 - 35 years</option>
<option value="36-45">36 - 45 years</option>
<option value="46-60">46 - 60 years</option>
<option value="60+">60 and above</option>
</select><br>
<label for="email"><span id="nameRequired" class="required-symbol">*</span>Email Address:</label><br>
<input type="email" id="email" name="email" placeholder="Email Address" required=""><br>
<label for="email"><span id="nameRequired" class="required-symbol">*</span>Telephone Number:</label><br>
<input type="text" id="mobile_number" name="mobile_number" placeholder="Telephone Number" minlength="10" maxlength="10" required=""><br>
<label><span id="nameRequired" class="required-symbol">*</span>Gender:</label><br>
<input type="radio" id="male" name="gender" value="Male" required="">
<label for="male">Male</label>
<input type="radio" id="female" name="gender" value="Female">
<label for="female">Female</label>
<input type="radio" id="other" name="gender" value="Other">
<label for="other">Other</label>
<hr>
<label><span id="nameRequired" class="required-symbol">*</span>Are you the patient or are you related to the patient?</label><br>
<input type="radio" id="patient" name="relation" value="Patient" required="">
<label for="patient">Patient</label>
<input type="radio" id="related" name="relation" value="Related">
<label for="related">Related</label><br>
<hr>
<label for="diagnosisType"><span id="nameRequired" class="required-symbol">*</span>Is the cancer diagnosed or suspected?</label>
<select id="diagnosisType" name="diagnosisType" onchange="handleDropdownChange()" required="">
<option value="">Select</option>
<option value="Diagnosed">Diagnosed</option>
<option value="Suspected">Suspected</option>
<option value="Not Sure">Not Sure</option>
</select>
<div id="locationField" style="display: none;">
<label for="locationInput">Specify location of cancer:</label>
<input type="text" id="locationInput" name="locationInput">
</div>
<hr>
<p style="font-size: 14px; font-weight: bold; ">Following questions are optional, however it will help us to assist you better if you answer them.</p>
<label>Have you done any testing?</label><br>
<input type="radio" id="testingYes" name="testing" value="Yes">
<label for="testingYes">Yes</label>
<input type="radio" id="testingNo" name="testing" value="No">
<label for="testingNo">No</label>
<hr>
<div id="testingOptions" style="display: none;">
<label>Which tests have you done?</label><br>
<input type="checkbox" id="bloodwork" name="tests[]" value="Bloodwork">
<label for="bloodwork">Blood work</label>
<input type="checkbox" id="biopsy" name="tests[]" value="Biopsy">
<label for="biopsy">Biopsy</label>
<input type="checkbox" id="scans" name="tests[]" value="Scans">
<label for="scans">Radiological scans</label>
<hr>
</div>
<label for="insurance">Do you have medical insurance?</label>
<select name="insurance" id="insurance">
<option value="yes">Yes</option>
<option value="no">No</option>
</select>
<label>Have you gotten an expert second opinion?</label><br>
<input type="radio" id="opinionYes" name="opinion" value="Yes">
<label for="opinionYes">Yes</label>
<input type="radio" id="opinionNo" name="opinion" value="No">
<label for="opinionNo">No</label>
<div id="noOpinionReason" style="display: none;">
<label for="noOpinionReason"> Why not?</label>
<input type="text" id="noOpinionReason" name="noOpinionReason">
</div>
<hr>
<label>Are you interested in getting another expert opinion?</label><br>
<input type="radio" id="interestedYes" name="interested" value="Yes">
<label for="interestedYes">Yes</label>
<input type="radio" id="interestedNo" name="interested" value="No">
<label for="interestedNo">No</label><br>
<div id="furtherDiscussion" style="display: none;">
<label>Are you interested in us getting in touch with you for a detailed discussion?</label><br>
<input type="radio" id="discussionYes" name="discussion" value="Yes">
<label for="discussionYes">Yes</label>
<input type="radio" id="discussionNo" name="discussion" value="No">
<label for="discussionNo">No</label><br>
</div>
<hr>
<label for="remark">Special Remark:</label>
<br>
<textarea name="remark" id="remark" rows="4" cols="50" maxlength="500000" oninput="countCharacters(this)"></textarea>
<br>
<!-- reCAPTCHA widget -->
<!-- <div class="g-recaptcha" data-sitekey="6Ldfxr0pAAAAAFzy5iz3D90fiX2DROREg-JhwPlk" data-callback="recaptchaCallback" required></div> -->
<br>
<input type="submit" name="inquiry_witin" value="Submit" onlick="validateForm()">
</form>Text Content
cancer patient cancer patients WHEN WAS THE LAST TIME YOU FELT JOY ? We take the pain of search out of your cancer journey Menu * Home Page FIND AI-MATCHED DOCTORS JUST FOR YOU Using our proprietary technology, reduce any chances of miscommunication, lack of feeling heard or misunderstood, and more importantly get the correct diagnosis and treatment plan in the quickest time. Inquire within FIND THE PEACE OF MIND, REDUCE ANXIETY AND WORRY AS YOU NAVIGATE THE CANCER JOURNEY Find the best-matched oncologist and other cancer services ENABLE LIFE IN YEARS Love playing with your pet? Or spending time with your family? Enjoy gardening, cooking, teaching or dancing? Now, you can make all that possible by staying stress-free, with our cutting edge technology that enables doctor-patient matching with a high degree of accuracy, and stays with you for your cancer-related needs in your journey. drbot.health presented/participated in: * * * * * * * * Contact Us Your email address Message Send Tweet Subscribe to our Newsletter Subscribe! Visitor Count × *Name *Location: *Age Bracket: Please Select Age < 25 years 25 - 35 years 36 - 45 years 46 - 60 years 60 and above *Email Address: *Telephone Number: *Gender: Male Female Other -------------------------------------------------------------------------------- *Are you the patient or are you related to the patient? Patient Related -------------------------------------------------------------------------------- *Is the cancer diagnosed or suspected? Select Diagnosed Suspected Not Sure Specify location of cancer: -------------------------------------------------------------------------------- Following questions are optional, however it will help us to assist you better if you answer them. Have you done any testing? Yes No -------------------------------------------------------------------------------- Which tests have you done? Blood work Biopsy Radiological scans -------------------------------------------------------------------------------- Do you have medical insurance? Yes No Have you gotten an expert second opinion? Yes No Why not? -------------------------------------------------------------------------------- Are you interested in getting another expert opinion? Yes No Are you interested in us getting in touch with you for a detailed discussion? Yes No -------------------------------------------------------------------------------- Special Remark: © 2024 All rights reserved. Name and logo are trademarks of drbot.