objednavka.drdigital.cz
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81.31.47.204
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Submitted URL: http://objednavka.drdigital.cz/
Effective URL: https://objednavka.drdigital.cz/
Submission: On August 02 via api from CZ — Scanned from DE
Effective URL: https://objednavka.drdigital.cz/
Submission: On August 02 via api from CZ — Scanned from DE
Form analysis 1 forms found in the DOM
POST /
<form action="/" method="post" data-adt-submit-form="" id="frm-form-form" class="ajax" novalidate="">
<div id="snippet-frm-form-form-errors"></div>
<div class="row">
<div class="mt-0 col-sm-6">
<div class="mb-3 required">
<label class="form-label required" for="frm-form-form-firstName">Jméno</label>
<input type="text" name="firstName" class="form-control text" id="frm-form-form-firstName" required="" data-nette-rules="[{"op":":filled","msg":"Pole je povinné."}]">
<div class="invalid-feedback" id="snippet-frm-form-form-firstName-errors"></div>
</div>
</div>
<div class="mt-0 col-sm-6">
<div class="mb-3 required">
<label class="form-label required" for="frm-form-form-lastName">Příjmení</label>
<input type="text" name="lastName" class="form-control text" id="frm-form-form-lastName" required="" data-nette-rules="[{"op":":filled","msg":"Pole je povinné."}]">
<div class="invalid-feedback" id="snippet-frm-form-form-lastName-errors"></div>
</div>
</div>
</div>
<div class="row">
<div class="col-sm-6">
<div class="mb-3 required">
<label class="form-label required" for="frm-form-form-email">E-mail</label>
<input type="email" name="email" class="form-control text" id="frm-form-form-email" required=""
data-nette-rules="[{"op":":filled","msg":"Pole je povinné."},{"op":":email","msg":"Invalid email address."},{"op":"ADT\\EmailStrictInput::validateEmail","msg":"Invalid email address."}]">
<div class="invalid-feedback" id="snippet-frm-form-form-email-errors"></div>
</div>
</div>
<div class="col-sm-6">
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<label class="form-label required" for="frm-form-form-phone">Telefon</label>
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</select></div>
<div class="col-7"><input type="text" id="frm-form-form-phone" data-nette-rules="[{"op":":filled","msg":"Pole je povinné."}]" name="phoneNationalNumber" required="" class="form-control">
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</div>
</div>
</div>
</div>
</div>
<hr class="my-4">
<div class="mb-3 required">
<label class="form-label required" for="frm-form-form-street">Ulice a číslo domu</label>
<input type="text" name="street" class="form-control text" id="frm-form-form-street" required="" data-nette-rules="[{"op":":filled","msg":"Pole je povinné."}]">
<div class="invalid-feedback" id="snippet-frm-form-form-street-errors"></div>
</div>
<div class="row">
<div class="col-sm-8">
<div class="mb-3 required">
<label class="form-label required" for="frm-form-form-city">Město</label>
<input type="text" name="city" class="form-control text" id="frm-form-form-city" required="" data-nette-rules="[{"op":":filled","msg":"Pole je povinné."}]">
<div class="invalid-feedback" id="snippet-frm-form-form-city-errors"></div>
</div>
</div>
<div class="col-sm-4">
<div class="mb-3 required">
<label class="form-label required" for="frm-form-form-zip">PSČ</label>
<input type="text" name="zip" class="form-control text" id="frm-form-form-zip" required="" data-nette-rules="[{"op":":filled","msg":"Pole je povinné."}]">
<div class="invalid-feedback" id="snippet-frm-form-form-zip-errors"></div>
</div>
</div>
</div>
<hr class="my-4">
<div class="mb-3 required">
<div class="form-check">
<input type="checkbox" name="terms" class="form-check-input" id="frm-form-form-terms" required="" data-nette-rules="[{"op":":filled","msg":"Musíte souhlasit s podmínkami."}]">
<label class="form-check-label" for="frm-form-form-terms">Souhlasím s obchodními podmínkami (<a href="https://drdigital.cz/vop/" target="_blank">zobrazit</a>)</label>
<div class="invalid-feedback" id="snippet-frm-form-form-terms-errors"></div>
</div>
</div>
<div class="mt-4 text-center">
<button type="submit" name="_submit" class="btn btn-primary btn-lg">Objednat</button>
</div>
<input type="hidden" name="_do" value="form-form-submit">
</form>Text Content
PROGRAM PREVENCE DR. DIGITAL Objednávkový formulář BALÍČEK OBSAHUJE: * Moderní tablet, nastavený na užívání služby. * Certifikovaný zdravotní přístroj pro měření životních funkcí. SLUŽBA ZAHRNUJE: * Péči Dr. Digital na 3 měsíce, včetně pravidelných prohlídek * Přístup do Virtuální kliniky a všech jejích funkcí. * Osobní koordinátor péče. Cena: 7 500 Kč Jméno Příjmení E-mail Telefon +1+7+20+27+30+31+32+33+34+36+39+40+41+43+44+45+46+47+48+49+51+52+53+54+55+56+57+58+60+61+62+63+64+65+66+81+82+84+86+90+91+92+93+94+95+98+211+212+213+216+218+220+221+222+223+224+225+226+227+228+229+230+231+232+233+234+235+236+237+238+239+240+241+242+243+244+245+246+247+248+249+250+251+252+253+254+255+256+257+258+260+261+262+263+264+265+266+267+268+269+290+291+297+298+299+350+351+352+353+354+355+356+357+358+359+370+371+372+373+374+375+376+377+378+380+381+382+383+385+386+387+389+420+421+423+500+501+502+503+504+505+506+507+508+509+590+591+592+593+594+595+596+597+598+599+670+672+673+674+675+676+677+678+679+680+681+682+683+685+686+687+688+689+690+691+692+800+808+850+852+853+855+856+870+878+880+881+882+883+886+888+960+961+962+963+964+965+966+967+968+970+971+972+973+974+975+976+977+979+992+993+994+995+996+998 -------------------------------------------------------------------------------- Ulice a číslo domu Město PSČ -------------------------------------------------------------------------------- Souhlasím s obchodními podmínkami (zobrazit) Objednat © 2024 Dr. Digital