jellyvision.lp.page Open in urlscan Pro
2606:4700:4400::ac40:99a8  Public Scan

Form analysis
1 forms found in the DOM

POST https://jellyvision.activehosted.com/proc.php

<form method="POST" action="https://jellyvision.activehosted.com/proc.php" id="_form_6628CC211EB8A_" class="_form _form_30 _inline-form _dark ng-pristine ng-valid" novalidate="" data-styles-version="5">
  <input type="hidden" name="u" value="6628CC211EB8A" data-name="u" autocomplete="off">
  <input type="hidden" name="f" value="30" data-name="f" autocomplete="off">
  <input type="hidden" name="s" data-name="s" autocomplete="off">
  <input type="hidden" name="c" value="0" data-name="c" autocomplete="off">
  <input type="hidden" name="m" value="0" data-name="m" autocomplete="off">
  <input type="hidden" name="act" value="sub" data-name="act" autocomplete="off">
  <input type="hidden" name="v" value="2" data-name="v" autocomplete="off">
  <input type="hidden" name="or" value="969457dcd86fa30219ae066ba64132a5" data-name="or" autocomplete="off">
  <div class="_form-content">
    <div class="_form_element _x92562423 _full_width ">
      <label for="email" class="_form-label">Email*</label>
      <div class="_field-wrapper">
        <input type="text" id="email" name="email" placeholder="Type your email" required="" data-name="email">
      </div>
    </div>
    <div class="_form_element _x68021535 _full_width ">
      <fieldset class="_form-fieldset">
        <div class="_row">
          <legend for="field[179][]" class="_form-label"> What preventive care services would you like to receive a reminder for? </legend>
        </div>
        <input data-autofill="false" type="hidden" id="field[179][]" name="field[179][]" value="~|" data-name="preventivecare24" autocomplete="off">
        <div class="_row _checkbox-radio">
          <input id="field_179Annual physical" type="checkbox" name="field[179][]" value="Annual physical" data-name="preventivecare24">
          <span><label for="field_179Annual physical">Annual physical</label></span>
        </div>
        <div class="_row _checkbox-radio">
          <input id="field_179Vision" type="checkbox" name="field[179][]" value="Vision" data-name="preventivecare24">
          <span><label for="field_179Vision">Vision</label></span>
        </div>
        <div class="_row _checkbox-radio">
          <input id="field_179Dental" type="checkbox" name="field[179][]" value="Dental" data-name="preventivecare24">
          <span><label for="field_179Dental">Dental</label></span>
        </div>
        <div class="_row _checkbox-radio">
          <input id="field_179Mental health" type="checkbox" name="field[179][]" value="Mental health" data-name="preventivecare24">
          <span><label for="field_179Mental health">Mental health</label></span>
        </div>
        <div class="_row _checkbox-radio">
          <input id="field_179Flu shot" type="checkbox" name="field[179][]" value="Flu shot" data-name="preventivecare24">
          <span><label for="field_179Flu shot">Flu shot</label></span>
        </div>
      </fieldset>
    </div>
    <div class="_button-wrapper _full_width"><button id="_form_30_submit" class="_submit" type="submit">Submit</button></div>
    <div class="_clear-element"></div>
  </div>
  <div class="_form-thank-you" style="display:none;"></div>
</form>

Text Content

Email*

What preventive care services would you like to receive a reminder for?
Annual physical
Vision
Dental
Mental health
Flu shot
Submit



ALEX

They say an apple a day keeps the doctor away, but that doesn’t mean you
shouldn’t go to the doctor. In fact, going to the doctor is best done routinely!

RELATED TOPICS

Getting started with preventive care

Level up with in-network providers

6 ways to save on medical care

©2001-2023 The Jellyvision Lab Inc. All Rights Reserved.

Privacy Policy | Terms of Service

Built with