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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">
  <div class="col-6">
    <input type="text" id="name" name="name" class="form-control" placeholder="Full name">
  </div>
  <div class="col-6">
    <input type="email" id="email" name="email" class="form-control" placeholder="Email address">
  </div>
  <div class="col-6">
    <input type="text" id="dob" name="dob" class="form-control" placeholder="Your Date of Birth">
  </div>
  <div class="col-6">
    <input type="text" id="phone" name="phone_number" class="form-control" placeholder="Phone number">
  </div>
  <div class="col-6">
    <input type="text" id="state" name="state" class="form-control" placeholder="Your State">
  </div>
  <div class="col-6">
    <input type="text" id="city" name="city" class="form-control" placeholder="Your City">
  </div>
  <div class="col-12">
    <textarea id="street" name="street" class="form-control" rows="5" placeholder="Your street"></textarea>
  </div>
  <input type="checkbox" name="agreement" value="1" style="height: 18px;width: 18px;margin: 4px 0px 0px 15px;">
  <div style="margin: -27px 50px 16px"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from EA 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="col-12" style="display: flex;justify-content: space-around;">
    <button class="form-control" type="submit" style="width: 100px;background-color: #ffa500;">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

EA HEALTH
 * Home
 * Terms Conditions
 * Privacy Policy


 * EA HEALTH


EMILIA ANDRES

I'm a Healthcare plans advisor that helps individuals and families to find the
right affordable health coverage that meets their health protection needs by
understanding what they are looking for and filtering all available plan options
to get that best match possible.




HOW WE HELP YOU




HEALTHCARE PLANS CONSULTATION

Let us guide you in choosing the perfect healthcare plan that fits your needs
and budget. Our team of experts will provide personalized recommendations based
on your specific health protection requirements.


AFFORDABLE COVERAGE OPTIONS

We understand the importance of finding affordable health insurance for
individuals and families. With our extensive knowledge and resources, we can
help you find the best coverage at a price that works for you.


CUSTOMIZED HEALTH INSURANCE SOLUTIONS

Every person's healthcare needs are unique, which is why we offer customized
health insurance solutions tailored to your individual needs. Our goal is to
ensure that you have comprehensive coverage for all your medical requirements.


LET'S CONNECT




OUR ADDRESS

+17022782177

emysusana12@gmail.com

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