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productquery.speakhealth.in Open in urlscan Pro
52.66.180.102  Public Scan

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URL: https://productquery.speakhealth.in/
Submission: On February 25 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

Name: form_232142726281451 — POST https://productquery.speakhealth.in/submit.php

<form class="jotform-form" action="https://productquery.speakhealth.in/submit.php" method="post" name="form_232142726281451" id="232142726281451" accept-charset="utf-8" autocomplete="on">
  <div role="main" class="form-all">
    <ul class="form-section page-section">
      <li id="cid_5" class="form-input-wide" data-type="control_head">
        <img src="https://productquery.speakhealth.in/images/logo.png" alt="" width="100" class="img">
        <div class="form-header-group  header-default">
          <div class="header-text httar htvam ">
            <h2 id="header_5" class="form-header" data-component="header"> Product Query Form</h2>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_fullname" id="id_1"><label class="form-label form-label-top form-label-auto" id="label_1" for="first_1">Enter Name<span class="form-required"></span> </label>
        <div id="cid_1" class="form-input-wide jf-required">
          <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="name" name="name" class="form-textbox" data-defaultvalue=""
                autocomplete="section-input_1 given-name" size="10" value="" data-component="first" aria-labelledby="label_1 sublabel_1_first"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last">
              </span></span></div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_email" id="id_3"><label class="form-label form-label-top form-label-auto" id="label_3" for="input_3"> E-mail Id<span class="form-required">*</span> </label>
        <div id="cid_3" class="form-input-wide jf-required"> <input type="email" id="email" name="email" class="form-textbox validate[required, Email]" data-defaultvalue="" size="30" value="" placeholder="ex: myname@example.com"
            data-component="email" aria-labelledby="label_3"> </div>
      </li>
      <li class="form-line jf-required" data-type="control_email" id="id_3"><label class="form-label form-label-top form-label-auto" id="label_3" for="input_3"> Mobile number<span class="form-required">*</span> </label>
        <div id="cid_3" class="form-input-wide jf-required"> <input type="number" id="mobile" name="mobile" class="form-textbox validate[required]" data-defaultvalue="" size="10" value="" placeholder="ex: 9999999999" data-component="mobile"
            aria-labelledby="label_3"> </div>
      </li>
      <li class="form-line jf-required" data-type="control_textarea" id="id_4"><label class="form-label form-label-top form-label-auto" id="label_4" for="input_4"> Enter Query <span class="form-required">*</span> </label>
        <div id="cid_4" class="form-input-wide jf-required"> <textarea id="query" class="form-textarea validate[required]" name="query" cols="40" rows="4" data-component="textarea" placeholder="Type here" aria-labelledby="label_4"></textarea> </div>
      </li>
      <li class="form-line jf-required" data-type="control_email" id="id_3"><label class="form-label form-label-top form-label-auto" id="label_3" for="input_3"> Select Product Name<span class="form-required">*</span> </label>
        <div id="cid_3" class="form-input-wide jf-required">
          <select style="display: block;" class="form-textbox validate[required]" name="product" id="product">
            <option value="Axcer 90">Axcer 90</option>
            <option value="Cepodem 200">Cepodem 200</option>
            <option value="CHERICOF 12">CHERICOF 12</option>
            <option value="CHERICOF COUGH FORMULA 100ML">CHERICOF COUGH FORMULA 100ML</option>
            <option value="CHERICOF COUGH FORMULA 60ml">CHERICOF COUGH FORMULA 60ml</option>
            <option value="Gemer 2/500">Gemer 2/500</option>
            <option value="Istamet 50/500">Istamet 50/500</option>
            <option value="Levipil 500">Levipil 500</option>
            <option value="Montek-LC">Montek-LC</option>
            <option value="Mox 500">Mox 500</option>
            <option value="Mox CV 500/125">Mox CV 500/125</option>
            <option value="Moxclav 500/125">Moxclav 500/125</option>
            <option value="Oxra 10">Oxra 10</option>
            <option value="Pantocid 20">Pantocid 20</option>
            <option value="Pantocid 40">Pantocid 40</option>
            <option value="Pantocid D">Pantocid D</option>
            <option value="Pantocid DSR">Pantocid DSR</option>
            <option value="RIFAGUT 550">RIFAGUT 550</option>
            <option value="RIFAGUT400">RIFAGUT400</option>
            <option value="Rosuvas 10">Rosuvas 10</option>
            <option value="Rosuvas 20">Rosuvas 20</option>
            <option value="Rosuvas 40">Rosuvas 40</option>
            <option value="Rosuvas 5">Rosuvas 5</option>
            <option value="Silodal 8">Silodal 8</option>
            <option value="Silodal D 8/0.5">Silodal D 8/0.5</option>
            <option value="Sompraz D 20">Sompraz D 20</option>
            <option value="Sompraz D 40">Sompraz D 40</option>
            <option value="SPORIDEX CV TABLETS 375+125 MG">SPORIDEX CV TABLETS 375+125 MG</option>
            <option value="SPORIDEX CV TABLETS 750 +125 MG">SPORIDEX CV TABLETS 750 +125 MG</option>
            <option value="Ursocol 300">Ursocol 300</option>
            <option value="Volini Spray 40g">Volini Spray 40g</option>
          </select>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_checkbox" id="id_4">
        <div id="cid_4" class="form-input-wide jf-required">
          <div class="form-single-column">
            <span class="form-checkbox-item">
              <input type="checkbox" class="form-checkbox" id="agree" name="agree" value="Yes" required="">
              <label class="form-label form-label-top form-label-auto" id="label_4"> I agree and accept the <a target="_blank" href="https://productquery.speakhealth.in/privacy.php">Privacy Policy</a> and the
                <a target="_blank" href="https://productquery.speakhealth.in/terms.php">Terms of use</a> of this website. <span class="form-required">*</span>
              </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_button" id="id_2">
        <div id="cid_2" class="form-input-wide">
          <div class="g-recaptcha" data-sitekey="6LeGXs8nAAAAAM4LLMweEFIjL87lKL9ZEG5nlk5S">
            <div style="width: 304px; height: 78px;">
              <div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-bvcw043jpxkh" frameborder="0" scrolling="no"
                  sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
                  src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LeGXs8nAAAAAM4LLMweEFIjL87lKL9ZEG5nlk5S&amp;co=aHR0cHM6Ly9wcm9kdWN0cXVlcnkuc3BlYWtoZWFsdGguaW46NDQz&amp;hl=en&amp;v=1kRDYC3bfA-o6-tsWzIBvp7k&amp;size=normal&amp;cb=an6fcuyalr4s"></iframe>
              </div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
                style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
            </div><iframe style="display: none;"></iframe>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_button" id="id_2">
        <div id="cid_2" class="form-input-wide">
          <div data-align="center" class="form-buttons-wrapper form-buttons-center   jsTest-button-wrapperField"><button onclick="validationform()" id="input_2" type="button"
              class="form-submit-button form-submit-button-none submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content="">SUBMIT</button></div>
        </div>
      </li>
    </ul>
  </div>
  <script>
    JotForm.showJotFormPowered = "new_footer";
  </script>
  <script>
    JotForm.poweredByText = "Powered by Jotform";
    // 
  </script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="232142726281451-232142726281451">
  <script type="text/javascript">
    var all_spc = document.querySelectorAll("form[id='232142726281451'] .si" + "mple" + "_spc");
    for (var i = 0; i < all_spc.length; i++) {
      all_spc[i].value = "232142726281451-232142726281451";
    }
  </script>
</form>

Text Content

 * PRODUCT QUERY FORM

 * Enter Name
   
 * E-mail Id*
   
 * Mobile number*
   
 * Enter Query *
   
 * Select Product Name*
   Axcer 90 Cepodem 200 CHERICOF 12 CHERICOF COUGH FORMULA 100ML CHERICOF COUGH
   FORMULA 60ml Gemer 2/500 Istamet 50/500 Levipil 500 Montek-LC Mox 500 Mox CV
   500/125 Moxclav 500/125 Oxra 10 Pantocid 20 Pantocid 40 Pantocid D Pantocid
   DSR RIFAGUT 550 RIFAGUT400 Rosuvas 10 Rosuvas 20 Rosuvas 40 Rosuvas 5 Silodal
   8 Silodal D 8/0.5 Sompraz D 20 Sompraz D 40 SPORIDEX CV TABLETS 375+125 MG
   SPORIDEX CV TABLETS 750 +125 MG Ursocol 300 Volini Spray 40g
 * I agree and accept the Privacy Policy and the Terms of use of this website. *
 * 
 * SUBMIT