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Form analysis
2 forms found in the DOM

POST /create-contact.php

<form id="contact-form" class="contact__form" method="post" action="/create-contact.php">
  <div class="row control-group">
    <div class="col-6">
      <input type="text" id="name" name="name" class="form-control" placeholder="Full name">
    </div>
    <div class="col-6">
      <input type="email" id="email" name="email" class="form-control" placeholder="Email address">
    </div>
  </div>
  <div class="row control-group">
    <div class="col-6">
      <input type="text" id="dob" name="dob" class="form-control" placeholder="Your Date of Birth">
    </div>
    <div class="col-6">
      <input type="text" id="phone" name="phone_number" class="form-control" placeholder="Phone number">
    </div>
  </div>
  <div class="row control-group">
    <div class="col-6">
      <input type="text" id="state" name="state" class="form-control" placeholder="Your State">
    </div>
    <div class="col-6">
      <input type="text" id="city" name="city" class="form-control" placeholder="Your City">
    </div>
  </div>
  <div class="control-group">
    <textarea id="street" name="street" class="form-control" rows="5" placeholder="Your street"></textarea>
  </div>
  <div class="text-white">
    <input type="checkbox" name="agreement" value="1"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from NEW HEALTH AGENT 55. Message frequency may vary. Reply STOP to cancel, Reply
    HELP for contact information. message and date rates may apply <a class="text-primary" href="terms-conditions.html">Terms &amp; Conditions</a> | <a class="text-primary" href="privacy-policy.html">Privacy Policy</a>
  </div>
  <div class="text-center col-3 mt-3">
    <button class="btn btn-custom" type="submit">Send</button>
  </div>
</form>

POST /opt-contact.php

<form method="POST" action="/opt-contact.php">
  <div class="modal-body"><input type="text" class="form-control" placeholder="Phone" name="ph" required="">
  </div>
  <div class="modal-footer">
    <button type="button" class="btn btn-secondary closeModalButton">Close</button>
    <button type="submit" class="btn btn-primary">Submit</button>
  </div>
</form>

Text Content

NEW HEALTH AGENT 55


CALL US

+19452157601


EMAIL US

chandlersyt@gmail.com

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NEW HEALTH AGENT 55


NEW HEALTH AGENT 55


NEW HEALTH AGENT 55


NEW HEALTH AGENT 55


NEW HEALTH AGENT 55





CHANDLER WILSON

I am a Licensed health advisor that provides affordable healthcare plan options
to individuals and families who have been searching for the best fit with their
budget and health protection needs.


TAILORED SOLUTIONS


CUSTOMIZED HEALTHCARE PLANS

LET US HELP YOU FIND THE PERFECT HEALTHCARE PLAN THAT FITS YOUR BUDGET AND
PROVIDES THE BEST PROTECTION FOR YOU AND YOUR FAMILY.


AFFORDABLE HEALTH INSURANCE OPTIONS

WE OFFER A VARIETY OF AFFORDABLE HEALTH INSURANCE OPTIONS TO ENSURE THAT YOU
HAVE ACCESS TO QUALITY HEALTHCARE WITHOUT BREAKING THE BANK.


EXPERT HEALTH ADVICE

OUR TEAM OF LICENSED HEALTH ADVISORS WILL PROVIDE EXPERT ADVICE AND GUIDANCE TO
HELP YOU MAKE INFORMED DECISIONS ABOUT YOUR HEALTHCARE NEEDS.


GET IN TOUCH

I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from NEW HEALTH AGENT 55. Message
frequency may vary. Reply STOP to cancel, Reply HELP for contact information.
message and date rates may apply Terms & Conditions | Privacy Policy
Send


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