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my.primary.health Open in urlscan Pro
54.162.128.250  Public Scan

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Submitted URL: https://lnks.gd/l/eyJhbGciOiJIUzI1NiJ9.eyJidWxsZXRpbl9saW5rX2lkIjoxMTcsInVyaSI6ImJwMjpjbGljayIsImJ1bGxldGluX2lkI...
Effective URL: https://my.primary.health/l/churchilldowns?fbclid=IwAR1X0VzQ4NZDZxTe_p32l9U4sG9l4v3ANpSFNQrSS3_ju8-rypt6vimZK4k
Submission: On January 26 via api from BE — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://api.kustomerapp.com/v1/hooks/form/5ffe150d32c4a19ca48305ef/b38925aae4e653a827f28925810590e96bff7d36880457999ca5b7f1194e92a3

<form method="post" data-parsley-validate="true" action="https://api.kustomerapp.com/v1/hooks/form/5ffe150d32c4a19ca48305ef/b38925aae4e653a827f28925810590e96bff7d36880457999ca5b7f1194e92a3" id="kustomer_form" novalidate="">
  <input type="hidden" name="location_url" value="https://my.primary.health/l/churchilldowns?fbclid=IwAR1X0VzQ4NZDZxTe_p32l9U4sG9l4v3ANpSFNQrSS3_ju8-rypt6vimZK4k">
  <input type="hidden" name="test_group" value="churchilldowns">
  <input type="hidden" name="org" value="BluewaterDx Admin">
  <input type="hidden" name="org_support_phone" value="">
  <input type="hidden" name="org_email" value="">
  <input type="hidden" name="user_access_code" value="">
  <input type="hidden" name="_wpcf7_locale" value="">
  <input type="hidden" name="zen_subject" value="Website User Support">
  <div class="form-row">
    <div class="col-md-6">
      <label for="kustomer_contact_name" class="form-label">Contact Name *</label>
      <input type="text" name="zen_name" required="required" aria-required="true" class="form-control" id="kustomer_contact_name" placeholder="John Doe">
    </div>
    <div class="col-md-6">
      <label for="kustomer_email" class="form-label">Email *</label>
      <input type="email" name="zen_email" required="required" aria-required="true" class="form-control" id="kustomer_email" placeholder="Email">
    </div>
  </div>
  <div>
    <label for="kustomer_phone_number" class="form-label">Mobile Phone Number</label>
    <input type="tel" name="phone_number" autocomplete="tel-national" class="form-control" id="kustomer_phone_number" placeholder="Mobile Phone Number">
  </div>
  <div>
    <label for="kustomer_ticket_type" class="form-label">What is this regarding? *</label>
    <select id="kustomer_ticket_type" required="required" aria-required="true" name="ticket_type" class="form-control" data-parsley-is-selected="">
      <option></option>
      <option value="test">Test</option>
      <option value="vaccine">Vaccine</option>
      <option value="other">Other</option>
    </select>
  </div>
  <div>
    <label for="kustomer_confirmation_code" class="form-label">Confirmation Code (if known)</label>
    <input type="tel" name="appointment_access_code" autocomplete="tel-national" class="form-control" id="kustomer_confirmation_code">
  </div>
  <div class="form-row">
    <div class="col-md-6">
      <label for="inputCity" class="form-label">City</label>
      <input type="text" name="city" class="form-control" id="inputCity">
    </div>
    <div class="col-md-6">
      <label for="inputState" class="form-label">State</label>
      <select id="inputState" name="state" class="form-control">
        <option></option>
        <option value="AL">Alabama</option>
        <option value="AK">Alaska</option>
        <option value="AZ">Arizona</option>
        <option value="AR">Arkansas</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DE">Delaware</option>
        <option value="DC">District Of Columbia</option>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="HI">Hawaii</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="IA">Iowa</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Louisiana</option>
        <option value="ME">Maine</option>
        <option value="MD">Maryland</option>
        <option value="MA">Massachusetts</option>
        <option value="MI">Michigan</option>
        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
        <option value="MO">Missouri</option>
        <option value="MT">Montana</option>
        <option value="NE">Nebraska</option>
        <option value="NV">Nevada</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NY">New York</option>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PA">Pennsylvania</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VT">Vermont</option>
        <option value="VA">Virginia</option>
        <option value="WA">Washington</option>
        <option value="WV">West Virginia</option>
        <option value="WI">Wisconsin</option>
        <option value="WY">Wyoming</option>
      </select>
    </div>
  </div>
  <div>
    <label for="kustomer_message" class="form-label">Message *</label>
    <textarea class="form-control" required="required" aria-required="true" name="zen_desc" id="kustomer_message" rows="3"></textarea>
  </div>
  <button type="submit" class="btn btn-primary" id="kustomer_submit">Submit</button>
</form>

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