www.covid19pfizer.com Open in urlscan Pro
2606:4700::6812:842  Public Scan

Form analysis
1 forms found in the DOM

Name: signup — POST /

<form name="signup" action="/" method="post" onsubmit="return formValidate()" class="signupform" id="signupform">
  <div class="form-field firstname">
    <label class="label-fname italisize m_bottom" for="first_name">First Name</label>
    <input placeholder="" type="text" name="Firstname" maxlength="50" class="inputfname" id="first_name" index="1">
    <div id="firstname_error" class="error">Please enter your first name</div>
  </div>
  <div class="form-field lastname">
    <label class="label-lname italisize m_bottom" for="Last_name">Last Name</label>
    <input placeholder="" type="text" name="Lastname" maxlength="50" class="inputlname" id="Last_name" index="2">
    <div id="lastname_error" class="error">Please enter your last name</div>
  </div>
  <div class="form-field email">
    <label for="e_mail" class="label-email m_bottom">Email</label>
    <input type="email" placeholder="" id="e_mail" name="Email" class="inputemail" index="3">
    <div id="email_error" class="error">Please enter your email address. Example: yourname@example.com</div>
  </div>
  <div class="form-field zip-code">
    <label class="label-zipcode m_bottom" for="zip_code">ZIP Code (optional)</label>
    <input placeholder="" type="text" name="ZipCode" maxlength="50" class="zipcode" id="zip_code" index="4">
    <div id="zipcode_error" class="error">Please enter 5-digit ZIP code</div>
  </div>
  <br class="for-desktop-only">
  <div>
    <h3 class="interests_mb">Content Interests</h3>
  </div>
  <p class="content-header-p">I am interested in information for people who are (check all that apply):</p>
  <div class="age-info">
    <div class="checkbox checkbox-1">
      <input type="checkbox" id="sixtyfive" name="sixtyfive" value="65+ years of age" index="5A" class="agecheckbox">
      <label for="sixtyfive">65+ years of age</label>
    </div>
    <div class="checkbox checkbox-2">
      <input type="checkbox" id="eighteentosixtyfour" name="eighteentosixtyfour" value="18-64 years of age" index="5B" class="agecheckbox">
      <label for="eighteentosixtyfour">18-64 years of age</label>
    </div>
    <div class="checkbox checkbox-3">
      <input type="checkbox" id="twelvetoseventeen" name="twelvetoseventeen" value="12-17 years of age" index="5C" class="agecheckbox">
      <label for="twelvetoseventeen">12-17 years of age</label>
    </div>
    <div class="checkbox checkbox-4">
      <input type="checkbox" id="fivetoeleven" name="fivetoeleven" value="5-11 years of age" index="5D" class="agecheckbox">
      <label for="fivetoeleven">5-11 years of age</label>
    </div>
    <div class="checkbox checkbox-5">
      <input type="checkbox" id="sixmotofouryr" name="sixmotofouryr" value="6 months–4 years of age" index="5E" class="agecheckbox">
      <label for="sixmotofouryr">6 months–4 years of age</label>
    </div>
    <div class="checkbox checkbox-6">
      <input type="checkbox" id="immunocompromised" name="immunocompromised" value="Immunocompromised" index="5F" class="agecheckbox">
      <label for="immunocompromised">Immunocompromised</label>
    </div>
  </div>
  <div id="age_checkbox_error" class="error">Please select at least one option</div>
  <br>
  <div class="header_mt">
    <p class="content-header-p">I am interested in information for (check all that apply):</p>
  </div>
  <div class="series-info">
    <div class="checkbox-v2 checkbox-7">
      <input type="checkbox" id="primaryseries" name="primaryseries" value="Primary Series" index="6A" class="seriescheckbox">
      <label for="primaryseries">Primary Series</label>
    </div>
    <div class="checkbox-v2 checkbox-8 custom-margin-checkbox">
      <input type="checkbox" id="booster" name="booster" value="Booster" index="6B" class="seriescheckbox">
      <label for="booster">Booster</label>
    </div>
    <div id="series_checkbox_error" class="error">Please select at least one option</div>
  </div>
  <p class="disclaimer font-family-Noto-Sans">Pfizer understands your personal and health information is private. The information you provide will only be used by Pfizer and parties acting on its behalf to email you materials you requested and other
    helpful information about COVID-19, vaccines, offers, and service communications.</p>
  <div class="checkbox-div checkbox flex-item">
    <input type="checkbox" class="chck-input left-width-box" id="check_box" index="7" value="Yes">
    <label class="form-check-label" for="check_box" id="errMsg">By checking this box, I agree that I am 18 years of age or older.</label>
  </div>
  <div id="checkbox_error" class="error">Select to acknowledge agreement</div>
  <div class="signupbutton">
    <input type="submit" value="Submit Response" class="btn font-colour-FDFDFD" index="8">
  </div>
  <div class="required-fields">
    <p>All fields are required unless otherwise stated</p>
  </div>
</form>

Text Content

HOMEPAGE




HOMEPAGE


STAY UP-TO-DATE
WITH RESOURCES
AND INFORMATION

Sign-up now to stay informed on the latest news regarding COVID-19 and vaccine
options.

The following questions will help us provide you with the most relevant
information tailored to your needs.

All fields are required unless otherwise stated.



PERSONAL INFORMATION

First Name
Please enter your first name
Last Name
Please enter your last name
Email
Please enter your email address. Example: yourname@example.com
ZIP Code (optional)
Please enter 5-digit ZIP code



CONTENT INTERESTS

I am interested in information for people who are (check all that apply):

65+ years of age
18-64 years of age
12-17 years of age
5-11 years of age
6 months–4 years of age
Immunocompromised
Please select at least one option


I am interested in information for (check all that apply):

Primary Series
Booster
Please select at least one option

Pfizer understands your personal and health information is private. The
information you provide will only be used by Pfizer and parties acting on its
behalf to email you materials you requested and other helpful information about
COVID-19, vaccines, offers, and service communications.

By checking this box, I agree that I am 18 years of age or older.
Select to acknowledge agreement


All fields are required unless otherwise stated

Close


YOU ARE NOW
LEAVING [EXAMPLEURL.COM]


YOU ARE NOW
LEAVING [EXAMPLEURL.COM]

LINKS TO OTHER WEBSITES ARE PROVIDED AS A CONVENIENCE TO THE VIEWER.

Continue

Cancel

Terms of Use
Privacy Policy
Contact Us

This site is intended only for US residents. The information provided is for
educational purposes only and is not intended to replace discussions with a
healthcare provider.

© 2023 All rights reserved.
PP-CVV-2061