leafwell.com Open in urlscan Pro
76.76.21.21  Public Scan

Submitted URL: http://admin.leafwell.com/
Effective URL: https://leafwell.com/
Submission: On December 01 via api from US — Scanned from DE

Form analysis 2 forms found in the DOM

<form class="grid sm:self-start gap-x-3 sm:grid-cols-inline-form sm:justify-between sm:max-w-md gap-y-2 " novalidate="">
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        <option value="" disabled="" hidden="" selected="">Select State</option>
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        <option value="AR">Arkansas</option>
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        <option value="MA">Massachusetts</option>
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        <option value="MN">Minnesota</option>
        <option value="MS">Mississippi</option>
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        <option value="NE">Nebraska</option>
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        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
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  </div><button
    class="relative select-none cursor-pointer inline-grid gap-x-2 grid-flow-col items-center justify-center text-center text-sm font-heading transition-colors focus:outline-none outline-none cursor-pointer leading-none border rounded-md min-h-50 py-3 px-6 from-lilac-300 to-green hover:from-green hover:to-green border-none bg-gradient-to-tr hover:bg-green hover:text-black  "
    type="submit"><span class="transition-opacity ">Get started</span><span class="pointer-events-none transition-opacity absolute transform -translate-y-1/2 inset-1/2 -translate-x-1/2 h-5 w-5 opacity-0 " aria-hidden="true">
      <div class="lds-ring">
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<form class="grid " novalidate="">
  <div class="flex items-end md:items-stretch gap-x-2 md:gap-x-8 mt-0 mb-6 md:mt-6 h-15">
    <div class="flex gap-x-2 justify-center items-center	w-1/2 px-1 md:px-4 py-3 rounded border border-green cursor-pointer duration-300 h-12 md:h-auto bg-[#d5f7e9]"><img alt="user" loading="lazy" width="20" height="20" decoding="async" data-nimg="1"
        class="h-4 md:h-6  duration-300" src="/user.svg" style="color: transparent;">
      <p class="text-base leading-4  duration-300">For one person</p>
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    <div before="Apply here and save 10%"
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      <p class="text-base leading-4 opacity-50 duration-300">Refer and Save</p>
    </div>
  </div>
  <div class="js-form-field relative mb-6">
    <div class="grid gap-y-3 ">
      <div class="relative "><select id="stateCode-1pdkacl-1701417288663" name="stateCode" aria-label="Select your state" aria-invalid="false"
          class="bg-white placeholder-gray-600 appearance-none border rounded outline-none focus:outline-none transition-colors  border-gray-400 secondary:border-indigo-200 focus:border-lilac-500 focus:secondary:border-lilac-500 w-full p-3 bg-no-repeat bg-input-position bg-select bg-input-size overflow-ellipsis  ">
          <option value="" disabled="" hidden="">Select your state</option>
          <option value="AL">Alabama</option>
          <option value="AK">Alaska</option>
          <option value="AS">American Samoa</option>
          <option value="AZ">Arizona</option>
          <option value="AR">Arkansas</option>
          <option value="CA">California</option>
          <option value="CO">Colorado</option>
          <option value="CT">Connecticut</option>
          <option value="DE">Delaware</option>
          <option value="FL">Florida</option>
          <option value="GA">Georgia</option>
          <option value="GU">Guam</option>
          <option value="HI">Hawaii</option>
          <option value="ID">Idaho</option>
          <option value="IL">Illinois</option>
          <option value="IN">Indiana</option>
          <option value="IA">Iowa</option>
          <option value="KS">Kansas</option>
          <option value="KY">Kentucky</option>
          <option value="LA">Louisiana</option>
          <option value="ME">Maine</option>
          <option value="MD">Maryland</option>
          <option value="MA">Massachusetts</option>
          <option value="MI">Michigan</option>
          <option value="MN">Minnesota</option>
          <option value="MS">Mississippi</option>
          <option value="MO">Missouri</option>
          <option value="MT">Montana</option>
          <option value="NE">Nebraska</option>
          <option value="NV">Nevada</option>
          <option value="NH">New Hampshire</option>
          <option value="NJ">New Jersey</option>
          <option value="NM">New Mexico</option>
          <option value="NY">New York</option>
          <option value="NC">North Carolina</option>
          <option value="ND">North Dakota</option>
          <option value="MP">Northern Mariana Islands</option>
          <option value="OH">Ohio</option>
          <option value="OK">Oklahoma</option>
          <option value="OR">Oregon</option>
          <option value="PA">Pennsylvania</option>
          <option value="PR">Puerto Rico</option>
          <option value="RI">Rhode Island</option>
          <option value="SC">South Carolina</option>
          <option value="SD">South Dakota</option>
          <option value="TN">Tennessee</option>
          <option value="TX">Texas</option>
          <option value="VI">US Virgin Islands</option>
          <option value="UT">Utah</option>
          <option value="VT">Vermont</option>
          <option value="VA">Virginia</option>
          <option value="WA">Washington</option>
          <option value="DC">Washington DC</option>
          <option value="WV">West Virginia</option>
          <option value="WI">Wisconsin</option>
          <option value="WY">Wyoming</option>
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    </div>
  </div>
  <div class="js-form-field relative mb-6">
    <div class="grid gap-y-3 "><input
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        placeholder="Email" type="email" id="patient_registry_email-yt0c68n-1701417288664" name="patient_registry_email" value=""></div>
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  <div class="js-form-field relative mb-6">
    <div class="grid gap-y-3 "><input
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        placeholder="Cell Phone Number" type="tel" id="patient_registry_phone-hzd44gd-1701417288664" name="patient_registry_phone" value=""></div>
    <p class="mt-2 text-xs">Please add an international code if your number isn't a US number</p>
  </div>
  <div class="js-form-field relative mb-6">
    <div class="grid gap-y-3 ">
      <div class="relative grid gap-x-2 grid-cols-2-auto content-start border-gray-300" id="patient_registry_accepted_terms_of_service-ax0l3qf-1701417288664"><input class="absolute w-full h-full opacity-0 left-0 top-0 cursor-pointer"
          id="patient_registry_accepted_terms_of_service-d1u4i6e-1701417288665" name="patient_registry_accepted_terms_of_service" invalid="false" type="checkbox" value="1"><span aria-hidden="true"
          class="bg-white placeholder-gray-600 appearance-none border rounded outline-none focus:outline-none transition-colors  border-gray-400 secondary:border-indigo-200 focus:border-lilac-500 focus:secondary:border-lilac-500 bg-contain block cursor-pointer w-5 h-5 p-0"></span><label
          class="prose select-none relative text-sm cursor-pointer " for="patient_registry_accepted_terms_of_service-d1u4i6e-1701417288665">
          <p>I have read and accept the <a target="_blank" href="https://leafwell.com/terms-of-use">terms of service</a> and <a target="_blank" href="https://leafwell.com/privacy-policy">privacy policy</a></p>
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  <div class="c-form__actions"><button
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      type="submit" name="commit" id="submitt_embeded_step_1" data-disable-with="Get Started"><span class="transition-opacity ">Get Started</span><span
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        <div class="lds-ring">
          <div></div>
          <div></div>
          <div></div>
          <div></div>
        </div>
      </span></button></div>
</form>

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Select your stateAlabamaAlaskaAmerican
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HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana
IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUS Virgin IslandsUtahVermontVirginiaWashingtonWashington
DCWest VirginiaWisconsinWyoming


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