weightloss.deliverxdfl.com
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https://weightloss.deliverxdfl.com/
Submission: On September 03 via automatic, source certstream-suspicious — Scanned from US
Submission: On September 03 via automatic, source certstream-suspicious — Scanned from US
Form analysis 2 forms found in the DOM
Name: quizForm1 — POST /
<form name="quizForm1" id="quizForm1" action="/" method="POST" class="qsm-quiz-form qmn_quiz_form mlw_quiz_form" novalidate="" enctype="multipart/form-data">
<input type="hidden" name="qsm_hidden_questions" id="qsm_hidden_questions" value="">
<input type="hidden" name="qsm_nonce" id="qsm_nonce_1" value="ad7a2c0653">
<input type="hidden" name="qsm_unique_key" id="qsm_unique_key_1" value="66d680567a619">
<div id="mlw_error_message" class="qsm-error-message qmn_error_message_section"></div>
<span id="mlw_top_of_quiz"></span>
<section class="qsm-page qsm-question-page animated pulse qsm-page-2" data-pid="2" data-qpid="1" data-prevbtn="0" style="">
<div class="quiz_section qsm-question-wrapper question-type-4 question-section-id-1 " data-qid="1">
<div class="mlw_qmn_new_question">What Are Your Goals For This Treatment? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p>Select all that apply</p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_check_answers ">
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question1[]" id="question1_1" value="0">
<label class="qsm-input-label" for="question1_1"> Remove stubborn fat </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question1[]" id="question1_2" value="1">
<label class="qsm-input-label" for="question1_2"> Fit into smaller clothes </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question1[]" id="question1_3" value="2">
<label class="qsm-input-label" for="question1_3"> Boost self-confidence </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question1[]" id="question1_4" value="3">
<label class="qsm-input-label" for="question1_4"> Tighten up loose skin </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question1[]" id="question1_5" value="4">
<label class="qsm-input-label" for="question1_5"> Feel comfortable in swim suit </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question1[]" id="question1_6" value="5">
<label class="qsm-input-label" for="question1_6"> Other </label>
</div>
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-3" data-pid="3" data-qpid="2" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-4 question-section-id-3 " data-qid="3">
<div class="mlw_qmn_new_question">What Area(s) Of The Body Are You Wanting To Improve? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p>Select all that apply</p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_check_answers ">
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question3[]" id="question3_1" value="0">
<label class="qsm-input-label" for="question3_1"> Abdomen </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question3[]" id="question3_2" value="1">
<label class="qsm-input-label" for="question3_2"> Buttocks </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question3[]" id="question3_3" value="2">
<label class="qsm-input-label" for="question3_3"> Chin/neck </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question3[]" id="question3_4" value="3">
<label class="qsm-input-label" for="question3_4"> Back </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question3[]" id="question3_5" value="4">
<label class="qsm-input-label" for="question3_5"> Hips/thighs </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question3[]" id="question3_6" value="5">
<label class="qsm-input-label" for="question3_6"> Chest (male) </label>
</div>
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-4" data-pid="4" data-qpid="3" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-0 question-section-id-4 " data-qid="4">
<div class="mlw_qmn_new_question">Has Previous Surgical Work Been Done On These Areas? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p></p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_radio_answers ">
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question4-1 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question4" id="question4_1" value="0">
<label class="qsm-input-label" for="question4_1"> Yes </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question4-2 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question4" id="question4_2" value="1">
<label class="qsm-input-label" for="question4_2"> No </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question4-3 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question4" id="question4_3" value="2">
<label class="qsm-input-label" for="question4_3"> It's complicated </label>
</div>
<label style="display: none !important;" for="question4_none">None</label>
<input type="radio" style="display: none;" name="question4" id="question4_none" checked="checked" value="">
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-5" data-pid="5" data-qpid="4" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-4 question-section-id-5 " data-qid="5">
<div class="mlw_qmn_new_question">Do You Have Any Of The Following Medical Issues? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p>Select all that apply</p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_check_answers ">
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_1" value="0">
<label class="qsm-input-label" for="question5_1"> Insulin Resistance </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_2" value="1">
<label class="qsm-input-label" for="question5_2"> Type 1 Diabetes </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_3" value="2">
<label class="qsm-input-label" for="question5_3"> High Blood Pressure </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_4" value="3">
<label class="qsm-input-label" for="question5_4"> Hypothyroidism </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_5" value="4">
<label class="qsm-input-label" for="question5_5"> Pre Diabetes </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_6" value="5">
<label class="qsm-input-label" for="question5_6"> Type 2 Diabetes </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_7" value="6">
<label class="qsm-input-label" for="question5_7"> Hyperthyroidism </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_8" value="7">
<label class="qsm-input-label" for="question5_8"> Other Medical Issue </label>
</div>
<div class="qsm_check_answer mrq_checkbox_class">
<input type="checkbox" class="qsm-multiple-response-input" name="question5[]" id="question5_9" value="8">
<label class="qsm-input-label" for="question5_9"> No Medical Issues </label>
</div>
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-6" data-pid="6" data-qpid="5" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-0 question-section-id-6 " data-qid="6">
<div class="mlw_qmn_new_question">How Many Days Per Week Are You Physically Active/Exercising? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p></p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_radio_answers ">
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question6-1 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question6" id="question6_1" value="0">
<label class="qsm-input-label" for="question6_1"> 0 days </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question6-2 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question6" id="question6_2" value="1">
<label class="qsm-input-label" for="question6_2"> 1 day </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question6-3 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question6" id="question6_3" value="2">
<label class="qsm-input-label" for="question6_3"> 2 days </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question6-4 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question6" id="question6_4" value="3">
<label class="qsm-input-label" for="question6_4"> 3 days </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question6-5 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question6" id="question6_5" value="4">
<label class="qsm-input-label" for="question6_5"> 4 days </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question6-6 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question6" id="question6_6" value="5">
<label class="qsm-input-label" for="question6_6"> 5+ days </label>
</div>
<label style="display: none !important;" for="question6_none">None</label>
<input type="radio" style="display: none;" name="question6" id="question6_none" checked="checked" value="">
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-7" data-pid="7" data-qpid="6" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-0 question-section-id-7 " data-qid="7">
<div class="mlw_qmn_new_question">Are You On Any Of The Following Diets? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p></p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_radio_answers ">
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question7-1 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question7" id="question7_1" value="0">
<label class="qsm-input-label" for="question7_1"> Keto </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question7-2 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question7" id="question7_2" value="1">
<label class="qsm-input-label" for="question7_2"> Paelo </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question7-3 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question7" id="question7_3" value="2">
<label class="qsm-input-label" for="question7_3"> Vegan </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question7-4 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question7" id="question7_4" value="3">
<label class="qsm-input-label" for="question7_4"> Vegetarian </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question7-5 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question7" id="question7_5" value="4">
<label class="qsm-input-label" for="question7_5"> Other/None </label>
</div>
<label style="display: none !important;" for="question7_none">None</label>
<input type="radio" style="display: none;" name="question7" id="question7_none" checked="checked" value="">
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-8" data-pid="8" data-qpid="7" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-0 question-section-id-8 " data-qid="8">
<div class="mlw_qmn_new_question">Any Questions About This Treatment? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p>Select all that apply</p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_radio_answers ">
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question8-1 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question8" id="question8_1" value="0">
<label class="qsm-input-label" for="question8_1"> What will my results look like? </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question8-2 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question8" id="question8_2" value="1">
<label class="qsm-input-label" for="question8_2"> How long will it take to see results? </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question8-3 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question8" id="question8_3" value="2">
<label class="qsm-input-label" for="question8_3"> What's the cost? </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question8-4 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question8" id="question8_4" value="3">
<label class="qsm-input-label" for="question8_4"> Is there financing available? </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question8-5 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question8" id="question8_5" value="4">
<label class="qsm-input-label" for="question8_5"> How many injections will I need? </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question8-6 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question8" id="question8_6" value="5">
<label class="qsm-input-label" for="question8_6"> Other </label>
</div>
<label style="display: none !important;" for="question8_none">None</label>
<input type="radio" style="display: none;" name="question8" id="question8_none" checked="checked" value="">
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-9" data-pid="9" data-qpid="8" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-0 question-section-id-9 " data-qid="9">
<div class="mlw_qmn_new_question">What Is Your Preferred Payment Method For This Treatment? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p></p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_radio_answers ">
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question9-1 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question9" id="question9_1" value="0">
<label class="qsm-input-label" for="question9_1"> Cash </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question9-2 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question9" id="question9_2" value="1">
<label class="qsm-input-label" for="question9_2"> Check </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question9-3 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question9" id="question9_3" value="2">
<label class="qsm-input-label" for="question9_3"> Credit Card </label>
</div>
<label style="display: none !important;" for="question9_none">None</label>
<input type="radio" style="display: none;" name="question9" id="question9_none" checked="checked" value="">
</div>
</fieldset>
</div>
</section>
<section class="qsm-page qsm-question-page animated pulse qsm-page-10" data-pid="10" data-qpid="9" data-prevbtn="0" style="display: none;">
<div class="quiz_section qsm-question-wrapper question-type-0 question-section-id-10 " data-qid="10">
<div class="mlw_qmn_new_question">What Day Would You Prefer For Your Consultation? </div>
<div class="mlw_qmn_question qsm_remove_bold">
<p></p>
</div>
<fieldset>
<legend></legend>
<div class="qmn_radio_answers ">
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question10-1 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question10" id="question10_1" value="0">
<label class="qsm-input-label" for="question10_1"> Monday </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question10-2 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question10" id="question10_2" value="1">
<label class="qsm-input-label" for="question10_2"> Tuesday </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question10-3 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question10" id="question10_3" value="2">
<label class="qsm-input-label" for="question10_3"> Wednesday </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question10-4 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question10" id="question10_4" value="3">
<label class="qsm-input-label" for="question10_4"> Thursday </label>
</div>
<div class="qmn_mc_answer_wrap mrq_checkbox_class" id="question10-5 ">
<input type="radio" class="qmn_quiz_radio qmn-multiple-choice-input " name="question10" id="question10_5" value="4">
<label class="qsm-input-label" for="question10_5"> Friday </label>
</div>
<label style="display: none !important;" for="question10_none">None</label>
<input type="radio" style="display: none;" name="question10" id="question10_none" checked="checked" value="">
</div>
</fieldset>
</div>
</section>
<section class="qsm-page" style="display: none;">
<div class="quiz_section">
<div class="qsm-after-message mlw_qmn_message_end">
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<div class="qsm_contact_div qsm-contact-type-text">
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<input type="text" class="mlwRequiredText qsm_required_text" name="contact_field_0" id="contact_field_0" value="" placeholder="Name">
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<span class="mlw_qmn_question qsm_question"><label for="contact_field_1">Email</label></span>
<input type="email" class="mlwEmail mlwRequiredText qsm_required_text" name="contact_field_1" id="contact_field_1" value="" placeholder="Email">
</div>
<div class="qsm_contact_div qsm-contact-type-text">
<span class="mlw_qmn_question qsm_question"><label for="contact_field_3">Phone</label></span>
<input type="text" class="mlwRequiredText qsm_required_textmlwPhoneNumber" name="contact_field_3" id="contact_field_3" value="" onkeydown="return event.keyCode !== 69" placeholder="Phone">
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</section>
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<div class="qsm-pagination qmn_pagination border margin-bottom">
<a class="qsm-btn qsm-previous qmn_btn mlw_qmn_quiz_link mlw_previous" href="javascript:void(0)" style="display: none;">Previous</a>
<span class="qmn_page_message"></span>
<div class="qmn_page_counter_message"></div>
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<a class="qsm-btn qsm-next qmn_btn mlw_qmn_quiz_link mlw_next mlw_custom_next" href="javascript:void(0)" style="">Next</a>
<input type="submit" class="qsm-btn qsm-submit-btn qmn_btn" value="Submit" style="display: none;">
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