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Submitted URL: https://fevertreefinance.evlink21.net/servlet/link/59244/572695/120940506/1907937
Effective URL: https://www.mediwallet.co.za/suggestYourDoctor?utm_source=MWDecNewsletter&utm_medium=email&utm_campaign=MWDecNewsletter&utm_c...
Submission: On December 13 via api from ZA — Scanned from DE

Form analysis 1 forms found in the DOM

/Home/SuggestPractice

<form id="myform" method="" action="/Home/SuggestPractice">
  <div class="form-group col-lg-6 col-sm-12">
    <label for="Name" class="required"> Your Name </label>
    <input type="text" required="" name="Name" class="form-control">
  </div>
  <div class="form-group col-lg-6 col-sm-12">
    <label for="Email" class="required"> Your Email Address </label>
    <input type="text" required="" name="Email" class="form-control">
  </div>
  <div class="form-group col-lg-6 col-sm-12">
    <label for="Email" class="required"> Suggested practice </label>
    <input type="text" name="Practice" class="form-control">
  </div>
  <div class="form-group col-lg-6 col-sm-12">
    <label for="Email" class="required"> Practice contact person </label>
    <input type="text" name="PracticeContact" class="form-control">
  </div>
  <div class="form-group col-lg-6 col-sm-12">
    <label for="Email" class="required"> Practice phone number </label>
    <input type="text" name="PracticePhone" class="form-control">
  </div>
  <div class="form-group col-lg-6 col-sm-12">
    <label for="Email" class="required"> Practice email address </label>
    <input type="text" name="PracticeEmail" class="form-control">
  </div>
  <div class="form-group  col-lg-12 col-sm-12">
    <label for="Message" class="required"> Comments </label>
    <textarea name="Comment" required="" class="form-control" rows="5"></textarea>
  </div>
  <div class="form-group  col-lg-12 col-sm-12">
    <p>
    </p>
    <div class="g-recaptcha" style="text-align: center;display: inline-block;" align="center" id="captcha" data-callback="imNotARobot" data-sitekey="6LeJ6b0ZAAAAACFnpaxG6I53WbmQDnliA9sEp9zZ">
      <div style="width: 304px; height: 78px;">
        <div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-2paqn0jy4rq6" 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=6LeJ6b0ZAAAAACFnpaxG6I53WbmQDnliA9sEp9zZ&amp;co=aHR0cHM6Ly93d3cubWVkaXdhbGxldC5jby56YTo0NDM.&amp;hl=de&amp;v=cwQvQhsy4_nYdnSDY4u7O5_B&amp;size=normal&amp;cb=sxw2vdu770rw"></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>
    </div>
    <span id="captchaSpan" style="color:red">
    </span>
  </div>
  <div class="form-group  col-lg-12 col-sm-12">
    <input type="button" id="sendSuggestion" value="Send suggestion" class="btn btn-primary btn-block" style="font-size:20px;">
  </div>
</form>

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SUGGEST A PRACTICE

Want to use your facility, but your preferred doctor isn't on the network? We
sign new practices up daily and would be happy to make contact and bring your
preferred medical professional on board.

 

Please complete the form below:

Your Name
Your Email Address
Suggested practice
Practice contact person
Practice phone number
Practice email address
Comments





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