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Submitted URL: https://mdnt.io/e/hUJcsDNugHb
Effective URL: https://patient.modento.io/north-branford-dental-group/forms/61627525?expires=1710598920&signature=5d351b8aa651fb6729f5a0da...
Submission: On February 18 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://patient.modento.io/north-branford-dental-group/forms/61627525?expires=1710598920&signature=5d351b8aa651fb6729f5a0da8a94429c4dbb03fe67422357307401bc2597b8e1&%24web_only=true&_branch_match_id=1287676526432134397&_branch_referrer=H4sIAAAAAAAAA8soKSkottLXz03JK9HLzNdP1c8I9UoudvErTfdIAgA5Hp4jHQAAAA%3D%3D

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  accept-charset="UTF-8"><input name="_token" type="hidden">
  <div class="main-card__content main-card__content--forms-show ">
    <h4 class="main-card__title"> Please "Fill out the required forms" listed below </h4>
    <div class="main-card__description">
    </div>
    <div class="forms-show__content">
      <ul class="forms-show__forms-check-list">
        <li>
          <label>
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            <span>Health History</span>
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        <li>
          <label>
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            <span>Dental History</span>
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        </li>
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        <li>
          <label>
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            <span>Dental Insurance Form</span>
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        <input class="form-control" id="spec_3656461" hidden="" name="form_spec_ids[]" type="number" value="3656461">
      </ul>
      <ul x-show="showOptional" class="forms-show__forms-check-list" style="display: none;">
        <li>
          <label>
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            <span>Contact Details</span>
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        </li>
        <li>
          <label>
            <input type="checkbox" class="filled-in" name="form_spec_ids[]" id="spec_3366332" value="3366332">
            <span>Update Patient Profile Photo</span>
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        </li>
        <li>
          <label>
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            <span>ID/License Update</span>
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        </li>
      </ul>
      <p x-show="!showOptional"> Alternatively, you can click on "I need to update my information" to see the optional forms in case something changed recently. </p>
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  </div>
  <div class="main-card__actions">
    <button x-show="!showOptional" type="submit" class="main-card__main-action-btn waves-effect waves-light btn-large button__primary"> Fill out the required forms </button>
    <button type="button" x-show="!showOptional" x-on:click.prevent="showOptional = true" class="main-card__main-action-btn waves-effect waves-light btn-large button__primary"> I need to update my information </button>
    <button x-show="showOptional" type="submit" class="main-card__main-action-btn waves-effect waves-light btn-large button__primary" style="display: none;"> Fill the selected forms </button>
  </div>
</form>

Text Content

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NORTH BRANFORD DENTAL GROUP

337 Notch Hill Road, North Branford
CT 06471
 * tel. (203) 488-6343
 * info@northbranforddental.com
 * www.northbranforddental.com/

NORTH BRANFORD DENTAL GROUP

337 Notch Hill Road, North Branford
CT 06471
 * tel. (203) 488-6343
 * info@northbranforddental.com
 * www.northbranforddental.com/

PLEASE "FILL OUT THE REQUIRED FORMS" LISTED BELOW


 * Health History
   
 * Dental History
   
 * Dental Insurance Form
   

 * Contact Details
 * Update Patient Profile Photo
 * ID/License Update

Alternatively, you can click on "I need to update my information" to see the
optional forms in case something changed recently.

Fill out the required forms I need to update my information Fill the selected
forms
337 Notch Hill Road, North Branford
CT 06471
 * tel. (203) 488-6343
 * info@northbranforddental.com
 * www.northbranforddental.com/