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Submission: On December 14 via manual from US — Scanned from DE
Submission: On December 14 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form class="f1b76ey0 form-container">
<div class="f10jhm76" id="red-error-msg" role="alert" tabindex="0" hidden="" aria-describedby="red_error_message" aria-label="Error">
<div id="red_error_message" class="warning">
<div class="fyj5ofj foundation-style">To continue, please fill in or correct the fields marked with red text.<br> If you need help, call us at 1-800-Teladoc (1-800-835-2362).</div>
</div>
<div class="error-list">
<div class="fngxb1j foundation-style"></div>
</div>
</div>
<div class="fngxb1j foundation-style registration-field-container">
<div class="f1vfyt1j foundation-style fo077u4">
<div>
<div class="f1mgyl9u">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="first_name" tabindex="-1">First Name</label><input id="first_name" type="text" inputmode="text" class="fjq2s7n foundation-style" maxlength="300" placeholder=""
name="firstName" role="textbox" aria-label="First Name" aria-required="true" value="">
<div class="input-bar f8ce5bf"></div>
</div>
</div>
</div>
</div>
<div class="fngxb1j foundation-style registration-field-container">
<div class="f1vfyt1j foundation-style fo077u4">
<div>
<div class="f1mgyl9u">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="last_name" tabindex="-1">Last Name</label><input id="last_name" type="text" inputmode="text" class="fjq2s7n foundation-style" maxlength="300" placeholder=""
name="lastName" role="textbox" aria-label="Last Name" aria-required="true" value="">
<div class="input-bar f8ce5bf"></div>
</div>
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</div>
<div class="fngxb1j foundation-style registration-field-container">
<div class="f1vfyt1j foundation-style fo077u4">
<div class="date-of-birth " aria-describedby="date-of-birth-label"><span id="date-of-birth-label">Date Of Birth:</span>
<div class="container-dob ">
<div class="row-m-d">
<div class="field" aria-label="Date Of Birth"><label for="month">Month</label><input type="text" id="month" maxlength="2" name="month" aria-required="true" aria-describedby="month" placeholder="MM" inputmode="numeric" value=""></div>
<div class="field" aria-label="Date Of Birth"><label for="day">Day</label><input type="text" id="day" maxlength="2" name="day" aria-required="true" aria-describedby="day" placeholder="DD" inputmode="numeric" value=""></div>
</div>
<div class="field year" aria-label="Date Of Birth"><label for="year">Year</label><input type="text" id="year" maxlength="4" name="year" aria-required="true" aria-describedby="year" placeholder="YYYY" inputmode="numeric" value=""></div>
</div>
</div>
</div>
</div>
<div class="fngxb1j foundation-style registration-field-container">
<div class="f14pfxr4 foundation-style fo077u4">
<div>
<div class="f1gfcnll">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="country_cd" tabindex="-1">Country</label><select id="country_cd" name="countryCd" class="f1rt5r2 foundation-style">
<option value="USA">United States Of America</option>
<option value="CAN">Canada</option>
<option value="DNK">Denmark</option>
<option value="AFG">Afghanistan</option>
<option value="ALB">Albania</option>
<option value="DZA">Algeria</option>
<option value="ASM">American Samoa</option>
<option value="AND">Andorra</option>
<option value="AGO">Angola</option>
<option value="AIA">Anguilla</option>
<option value="ATA">Antarctica</option>
<option value="ATG">Antigua and Barbuda</option>
<option value="ARG">Argentina</option>
<option value="ARM">Armenia</option>
<option value="ABW">Aruba</option>
<option value="AUS">Australia</option>
<option value="AUT">Austria</option>
<option value="AZE">Azerbaijan</option>
<option value="BHS">Bahamas</option>
<option value="BHR">Bahrain</option>
<option value="BGD">Bangladesh</option>
<option value="BRB">Barbados</option>
<option value="BLR">Belarus</option>
<option value="BEL">Belgium</option>
<option value="BLZ">Belize</option>
<option value="BEN">Benin</option>
<option value="BMU">Bermuda</option>
<option value="BTN">Bhutan</option>
<option value="BOL">Bolivia</option>
<option value="BES">Bonaire</option>
<option value="BIH">Bosnia and Herzegovina</option>
<option value="BWA">Botswana</option>
<option value="BRA">Brazil</option>
<option value="IOT">British Indian Ocean Territory</option>
<option value="VGB">British Virgin Islands</option>
<option value="BRN">Brunei</option>
<option value="BGR">Bulgaria</option>
<option value="BFA">Burkina Faso</option>
<option value="BDI">Burundi</option>
<option value="KHM">Cambodia</option>
<option value="CMR">Cameroon</option>
<option value="CPV">Cape Verde</option>
<option value="CYM">Cayman Islands</option>
<option value="CAF">Central African Republic</option>
<option value="TCD">Chad</option>
<option value="CHL">Chile</option>
<option value="CHN">China</option>
<option value="CXR">Christmas Island</option>
<option value="CCK">Cocos [Keeling] Islands</option>
<option value="COL">Colombia</option>
<option value="COM">Comoros</option>
<option value="COK">Cook Islands</option>
<option value="CRI">Costa Rica</option>
<option value="HRV">Croatia</option>
<option value="CUB">Cuba</option>
<option value="CUW">Curacao</option>
<option value="CYP">Cyprus</option>
<option value="CZE">Czechia</option>
<option value="COD">Democratic Republic of the Congo</option>
<option value="DJI">Djibouti</option>
<option value="DMA">Dominica</option>
<option value="DOM">Dominican Republic</option>
<option value="TLS">East Timor</option>
<option value="ECU">Ecuador</option>
<option value="EGY">Egypt</option>
<option value="SLV">El Salvador</option>
<option value="GNQ">Equatorial Guinea</option>
<option value="ERI">Eritrea</option>
<option value="EST">Estonia</option>
<option value="ETH">Ethiopia</option>
<option value="FLK">Falkland Islands</option>
<option value="FRO">Faroe Islands</option>
<option value="FJI">Fiji</option>
<option value="FIN">Finland</option>
<option value="FRA">France</option>
<option value="GUF">French Guiana</option>
<option value="PYF">French Polynesia</option>
<option value="ATF">French Southern Territories</option>
<option value="GAB">Gabon</option>
<option value="GMB">Gambia</option>
<option value="GEO">Georgia</option>
<option value="DEU">Germany</option>
<option value="GHA">Ghana</option>
<option value="GIB">Gibraltar</option>
<option value="GRC">Greece</option>
<option value="GRL">Greenland</option>
<option value="GRD">Grenada</option>
<option value="GLP">Guadeloupe</option>
<option value="GTM">Guatemala</option>
<option value="GGY">Guernsey</option>
<option value="GIN">Guinea</option>
<option value="GNB">Guinea-Bissau</option>
<option value="GUY">Guyana</option>
<option value="HTI">Haiti</option>
<option value="HND">Honduras</option>
<option value="HKG">Hong Kong</option>
<option value="HUN">Hungary</option>
<option value="ISL">Iceland</option>
<option value="IND">India</option>
<option value="IDN">Indonesia</option>
<option value="IRN">Iran</option>
<option value="IRQ">Iraq</option>
<option value="IRL">Ireland</option>
<option value="IMN">Isle of Man</option>
<option value="ISR">Israel</option>
<option value="ITA">Italy</option>
<option value="CIV">Ivory Coast</option>
<option value="JAM">Jamaica</option>
<option value="JPN">Japan</option>
<option value="JEY">Jersey</option>
<option value="JOR">Jordan</option>
<option value="KAZ">Kazakhstan</option>
<option value="KEN">Kenya</option>
<option value="KIR">Kiribati</option>
<option value="XKX">Kosovo</option>
<option value="KWT">Kuwait</option>
<option value="KGZ">Kyrgyzstan</option>
<option value="LAO">Laos</option>
<option value="LVA">Latvia</option>
<option value="LBN">Lebanon</option>
<option value="LSO">Lesotho</option>
<option value="LBR">Liberia</option>
<option value="LBY">Libya</option>
<option value="LIE">Liechtenstein</option>
<option value="LTU">Lithuania</option>
<option value="LUX">Luxembourg</option>
<option value="MAC">Macao</option>
<option value="MKD">Macedonia</option>
<option value="MDG">Madagascar</option>
<option value="MWI">Malawi</option>
<option value="MYS">Malaysia</option>
<option value="MDV">Maldives</option>
<option value="MLI">Mali</option>
<option value="MLT">Malta</option>
<option value="MHL">Marshall Islands</option>
<option value="MTQ">Martinique</option>
<option value="MRT">Mauritania</option>
<option value="MUS">Mauritius</option>
<option value="MYT">Mayotte</option>
<option value="MEX">Mexico</option>
<option value="FSM">Micronesia</option>
<option value="MDA">Moldova</option>
<option value="MCO">Monaco</option>
<option value="MNG">Mongolia</option>
<option value="MNE">Montenegro</option>
<option value="MSR">Montserrat</option>
<option value="MAR">Morocco</option>
<option value="MOZ">Mozambique</option>
<option value="MMR">Myanmar [Burma]</option>
<option value="NAM">Namibia</option>
<option value="NRU">Nauru</option>
<option value="NPL">Nepal</option>
<option value="NLD">Netherlands</option>
<option value="ANT">Netherlands Antilles</option>
<option value="NCL">New Caledonia</option>
<option value="NZL">New Zealand</option>
<option value="NIC">Nicaragua</option>
<option value="NER">Niger</option>
<option value="NGA">Nigeria</option>
<option value="NIU">Niue</option>
<option value="NFK">Norfolk Island</option>
<option value="PRK">North Korea</option>
<option value="NOR">Norway</option>
<option value="OMN">Oman</option>
<option value="PAK">Pakistan</option>
<option value="PLW">Palau</option>
<option value="PSE">Palestine</option>
<option value="PAN">Panama</option>
<option value="PNG">Papua New Guinea</option>
<option value="PRY">Paraguay</option>
<option value="PER">Peru</option>
<option value="PHL">Philippines</option>
<option value="PCN">Pitcairn Islands</option>
<option value="POL">Poland</option>
<option value="PRT">Portugal</option>
<option value="QAT">Qatar</option>
<option value="COG">Republic of the Congo</option>
<option value="ROU">Romania</option>
<option value="RUS">Russia</option>
<option value="RWA">Rwanda</option>
<option value="SHN">Saint Helena</option>
<option value="KNA">Saint Kitts and Nevis</option>
<option value="LCA">Saint Lucia</option>
<option value="MAF">Saint Martin</option>
<option value="SPM">Saint Pierre and Miquelon</option>
<option value="VCT">Saint Vincent and the Grenadines</option>
<option value="WSM">Samoa</option>
<option value="SMR">San Marino</option>
<option value="SAU">Saudi Arabia</option>
<option value="SEN">Senegal</option>
<option value="SRB">Serbia</option>
<option value="SCG">Serbia and Montenegro</option>
<option value="SYC">Seychelles</option>
<option value="SLE">Sierra Leone</option>
<option value="SGP">Singapore</option>
<option value="SXM">Sint Maarten</option>
<option value="SVK">Slovakia</option>
<option value="SVN">Slovenia</option>
<option value="SLB">Solomon Islands</option>
<option value="SOM">Somalia</option>
<option value="ZAF">South Africa</option>
<option value="SGS">South Georgia and the South Sandwich Islands</option>
<option value="KOR">South Korea</option>
<option value="SSD">South Sudan</option>
<option value="ESP">Spain</option>
<option value="LKA">Sri Lanka</option>
<option value="SDN">Sudan</option>
<option value="SUR">Suriname</option>
<option value="SJM">Svalbard and Jan Mayen</option>
<option value="SWZ">Swaziland</option>
<option value="SWE">Sweden</option>
<option value="CHE">Switzerland</option>
<option value="SYR">Syria</option>
<option value="TWN">Taiwan</option>
<option value="TJK">Tajikistan</option>
<option value="TZA">Tanzania</option>
<option value="THA">Thailand</option>
<option value="TGO">Togo</option>
<option value="TKL">Tokelau</option>
<option value="TON">Tonga</option>
<option value="TTO">Trinidad and Tobago</option>
<option value="TUN">Tunisia</option>
<option value="TUR">Turkey</option>
<option value="TKM">Turkmenistan</option>
<option value="TCA">Turks and Caicos Islands</option>
<option value="TUV">Tuvalu</option>
<option value="UMI">U.S. Minor Outlying Islands</option>
<option value="UGA">Uganda</option>
<option value="UKR">Ukraine</option>
<option value="ARE">United Arab Emirates</option>
<option value="GBR">United Kingdom</option>
<option value="URY">Uruguay</option>
<option value="UZB">Uzbekistan</option>
<option value="VUT">Vanuatu</option>
<option value="VAT">Vatican City</option>
<option value="VEN">Venezuela</option>
<option value="VNM">Vietnam</option>
<option value="WLF">Wallis and Futuna</option>
<option value="ESH">Western Sahara</option>
<option value="YEM">Yemen</option>
<option value="ZMB">Zambia</option>
<option value="ZWE">Zimbabwe</option>
</select>
<div class="input-bar f8ce5bf"></div>
</div>
<div></div>
</div>
</div>
<div class="f1vfyt1j foundation-style fo077u4">
<div>
<div class="f1mgyl9u">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="postal" tabindex="-1">Zip Code</label><input id="postal" type="text" inputmode="numeric" class="fjq2s7n foundation-style" maxlength="300"
placeholder="11111 or 11111-1111" name="zipCode" role="textbox" aria-label="Zip Code" aria-required="true" value="">
<div class="input-bar f8ce5bf"></div>
</div>
</div>
</div>
</div>
<div class="fngxb1j foundation-style registration-field-container">
<div class="f1vfyt1j foundation-style fo077u4">
<div>
<div class="f1mgyl9u">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="email_address" tabindex="-1">Email</label><input id="email_address" type="text" inputmode="text" class="fjq2s7n foundation-style" maxlength="300" placeholder=""
name="emailAddress" role="textbox" aria-label="Email" aria-required="true" value="">
<div class="input-bar f8ce5bf"></div>
</div>
</div>
</div>
</div>
<div class="fngxb1j foundation-style registration-field-container">
<div class="f14pfxr4 foundation-style fo077u4">
<div>
<div class="f1gfcnll">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="language" tabindex="-1">Preferred Language</label><select id="language" name="language" class="f1rt5r2 foundation-style">
<option value=""></option>
<option value="American Sign Language">American Sign Language</option>
<option value="Arabic">Arabic</option>
<option value="Danish">Danish</option>
<option value="English">English</option>
<option value="French">French</option>
<option value="German">German</option>
<option value="Hindi">Hindi</option>
<option value="Japanese">Japanese</option>
<option value="Korean">Korean</option>
<option value="Mandarin">Mandarin</option>
<option value="Portuguese">Portuguese</option>
<option value="Russian">Russian</option>
<option value="Spanish">Spanish</option>
<option value="Turkish">Turkish</option>
<option value="Vietnamese">Vietnamese</option>
<option value="Other">Other</option>
</select>
<div class="input-bar f8ce5bf"></div>
</div>
<div></div>
</div>
</div>
<div class="f1vfyt1j foundation-style fo077u4">
<div>
<div class="f1gfcnll">
<div class="input-bar fsx5x63"></div><label class="f1rzox04 f1sdn9ux f45h" for="gender" tabindex="-1">Biological Sex</label><select id="gender" name="gender" class="f1rt5r2 foundation-style">
<option value="">Please Select</option>
<option value="GENDER_MALE">Male</option>
<option value="GENDER_FEMALE">Female</option>
<option value="GENDER_OTHER">Other</option>
</select>
<div class="input-bar f8ce5bf"></div>
</div>
<div></div>
</div>
</div>
</div>
<div class="fngxb1j foundation-style promo-code-container">
<div class="f1vfyt1j foundation-style fo077u4">
<div>
<div class="f1f1ygnm"><input type="checkbox" name="hasPromoCode" id="has_promo_code" aria-label="I have a Teladoc Promo Code. (Optional)" class="f10mchk9 foundation-style" value="true"><label for="has_promo_code" class="" tabindex="-1"
aria-hidden="true"><span></span>I have a Teladoc Promo Code. (Optional)</label></div>
</div>
</div>
</div>
<div class="fyj5ofj foundation-style">
<div class="f1vfyt1j foundation-style continue-registration-button-container"><button id="continue-registration-button" class="cta-button blue chevron" type="submit" style="margin: 0px auto;"><span>Continue</span></button></div>
</div>
</form>Text Content
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