www.atmantan.com Open in urlscan Pro
68.183.80.216  Public Scan

Submitted URL: https://feedback.atmantan.com/
Effective URL: https://www.atmantan.com/contact-us
Submission: On September 21 via automatic, source certstream-suspicious — Scanned from DE

Form analysis 1 forms found in the DOM

Name: google-sheetPOST https://crm.zoho.com/crm/WebToLeadForm

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  <h4 class="h4style_all">You are one step closer to the most transformative experience</h4><br>
  <table class="box" style="background-color: white; color: black; border: none; opacity: 1;">
    <tbody>
      <tr>
        <td colspan="2" align="left" style="color:black;font-family:Arial;font-size:14px;word-break: break-word;"><strong></strong></td>
      </tr>
      <tr>
        <td class="formsmtitle"> What is your Wellness Objective ? <span style="color:red;">*</span> <select style="width:100%;box-sizing:border-box;" id="LEADCF11" name="LEADCF11" required="">
            <option value="" disabled="" selected="">Select</option>
            <option value="Healing/ Disease reversal">Healing/ Disease reversal</option>
            <option value="Immunity Boost">Immunity Boost</option>
            <option value="Detox">Detox</option>
            <option value="Weight Management">Weight Management</option>
            <option value="Relaxation">Relaxation</option>
            <option value="Stress Management">Stress Management</option>
            <option value="Fitness">Fitness</option>
            <option value="Ayurvedic Panchakarma">Ayurvedic Panchakarma</option>
            <option value="Emotional Healing">Emotional Healing</option>
            <option value="Injury Management/Rehab">Injury Management/Rehab</option>
            <option value="Other">Other</option>
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      </tr>
      <tr>
        <td class="formsmtitle"> Medical History <select id="LEADCF14" name="LEADCF14" multiple="" data-select2-id="select2-data-LEADCF14" tabindex="-1" class="select2-hidden-accessible" aria-hidden="true">
            <option value="None">None</option>
            <option value="Allergic Rhinitis">Allergic Rhinitis</option>
            <option value="Ankylosing Spondylitis">Ankylosing Spondylitis</option>
            <option value="Anxiety">Anxiety</option>
            <option value="Asthma">Asthma</option>
            <option value="Auto immune Disorder">Auto immune Disorder</option>
            <option value="Cancer">Cancer</option>
            <option value="Cardiac problems">Cardiac problems</option>
            <option value="Cervical/ Lumbar Spondylosis">Cervical/ Lumbar Spondylosis</option>
            <option value="Cholesterol">Cholesterol</option>
            <option value="Diabetes">Diabetes</option>
            <option value="Digestive disorders">Digestive disorders</option>
            <option value="Epilepsy">Epilepsy</option>
            <option value="Hypertension">Hypertension</option>
            <option value="Irritable Bowel Syndrome ( IBS )">Irritable Bowel Syndrome ( IBS )</option>
            <option value="Kidney diseases/stone">Kidney diseases/stone</option>
            <option value="Lupus (SLE)">Lupus (SLE)</option>
            <option value="Migraine">Migraine</option>
            <option value="Obesity">Obesity</option>
            <option value="Osteo - Arthritis">Osteo - Arthritis</option>
            <option value="Pacemaker">Pacemaker</option>
            <option value="PCOD">Polycystic Ovarian Disease (PCOD)</option>
            <option value="Prostate issues">Prostate issues</option>
            <option value="Rheumatoid Arthritis">Rheumatoid Arthritis</option>
            <option value="Skin diseases">Skin diseases</option>
            <option value="Thyroid problems">Thyroid problems</option>
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      <tr class="col-lg-12 col-md-12 col-xs-12">
        <td class="formsmtitle col-lg-4"> Height <input type="text" style="width:100%;box-sizing:border-box;" maxlength="255" id="LEADCF10" name="LEADCF10"></td>
        <td class="formsmtitle col-lg-4"> Weight <input type="text" style="width:100%;box-sizing:border-box;" maxlength="255" id="LEADCF12" name="LEADCF12"></td>
        <td class="formsmtitle col-lg-4">Age<input type="text" style="width:100%;box-sizing:border-box;" maxlength="9" id="LEADCF55" name="LEADCF55"></td>
        <td class="formsmtitle col-lg-12" style="float: left;width: 100%;">Do you have any other comment or health concerns?<textarea id="LEADCF4" name="LEADCF4" maxlength="2000" style="width:100%;">&nbsp;</textarea></td>
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      <tr class="col-lg-4">
        <td class="formsmtitle">Gender<span style="color:red;">*</span> <select style="width:100%;box-sizing:border-box;" id="LEADCF9" name="LEADCF9" required="">
            <option disabled="" selected="" value="">-Select-</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            <option value="Other">Other</option>
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      </tr>
      <tr class="col-lg-4 col-md-4">
        <td class="formsmtitle">First Name<span style="color:red;">*</span> <input type="text" style="width:100%;box-sizing:border-box;" maxlength="40" id="First_Name" name="First Name" required=""></td>
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      <tr class="col-lg-4 col-md-4">
        <td class="formsmtitle">Last Name<span style="color:red;">*</span><input type="text" style="width:100%;box-sizing:border-box;" maxlength="80" id="Last_Name" name="Last Name" required=""></td>
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      <tr>
        <td class="formsmtitle">Email<span style="color:red;">*</span> <input type="text" ftype="email" style="width:100%;box-sizing:border-box;" maxlength="100" id="Email" name="Email" required=""></td>
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      <tr>
        <td class="formsmtitle">Mobile<span style="color:red;">*</span> <input type="text" style="width:100%;box-sizing:border-box;" maxlength="30" id="Mobile" name="Mobile" required=""></td>
      </tr>
      <tr>
        <td class="formsmtitle">Nationality<span style="color:red;">*</span> <input type="text" style="width:100%;box-sizing:border-box;" maxlength="255" id="LEADCF7" name="LEADCF7" required=""></td>
      </tr>
      <tr style="display:none;">
        <td style="word-break: break-word;text-align:left;font-size:12px;font-family:Arial;width:30%">Lead Status</td>
        <td style="width:40%;"> <select style="width:100%;box-sizing:border-box;" id="Lead_Status" name="Lead Status">
            <option value="-None-">-None-</option>
            <option value="Qualified">Qualified</option>
            <option value="Contact in Future">Contact in Future</option>
            <option value="Junk Lead">Junk Lead</option>
            <option value="Not Qualified">Not Qualified</option>
            <option value="Other Department">Other Department</option>
            <option selected="" value="New Lead">New Lead</option>
            <option value="Not Contacted">Not Contacted</option>
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      <tr style="display:none;">
        <td style="word-break: break-word;text-align:left;font-size:12px;font-family:Arial;width:30%">Lead Source</td>
        <td style="width:40%;"> <select style="width:100%;box-sizing:border-box;" id="Lead_Source" name="Lead Source">
            <option value="-None-">-None-</option>
            <option value="Google Advertising">Google Advertising</option>
            <option value="Reference GM">Reference GM</option>
            <option value="Social Media">Social Media</option>
            <option value="Telephone">Telephone</option>
            <option value="Email">Email</option>
            <option value="Chat">Chat</option>
            <option value="Reference PR">Reference PR</option>
            <option value="Reference owner">Reference owner</option>
            <option selected="" value="Website">Website</option>
            <option value="Facebook">Facebook</option>
            <option value="Facebook Ads">Facebook Ads</option>
            <option value="Twitter">Twitter</option>
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      </tr>
      <tr>
        <td class="formsmtitle"> Enter the Captcha <input type="text" maxlength="10" name="enterdigest">
          <div class="zcwf_row">
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              <a href="javascript:;" onclick="reloadImg()">Reload</a></div>
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      </tr>
      <tr>
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    </tbody>
  </table>
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  </script>
</form>

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ATMANTAN WELLNESS CENTRE
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Maharashtra, India.
Telephone: +91 20 66766666


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info@atmantan.com



careers@atmantan.com

ATMANTAN WELLNESS RESORT Mulshi, Pune - 412108, Maharashtra, India.

Tel: +91 20 66766666

Pune Sales Office: SPARSH INFRATECH PVT. LTD. 3, Queens Garden, Pune – 411001

Tel: +91 20 2636 2222
Ext: 278

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We would love to help you in bettering your lifestyle and being transformed

reservations@atmantan.com

info@atmantan.com



careers@atmantan.com

ATMANTAN WELLNESS RESORT Mulshi, Pune - 412108, Maharashtra, India.

Tel: +91 20 66766666

Pune Sales Office: SPARSH INFRATECH PVT. LTD. 3, Queens Garden, Pune – 411001

Tel: +91 20 2636 2222
Ext: 278



ATMANTAN, Wellness Centre
Mulshi, Pune - 412108, Maharashtra, India

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