131226ikfx.leonardo-sites.com
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https://131226ikfx.leonardo-sites.com/
Submission: On June 21 via api from US — Scanned from DE
Submission: On June 21 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: apptform —
<form id="apptform" name="apptform">
<div class="col-md-6 col-sm-6 col-xs-12 appoint-left">
<div class="row">
<div class="col-md-12 form-wrap">
<div class="row dr-appoint-profile">
<div class="dr-appoint-pic col-xs-4 col-lg-4"><img src="https://sitebuilder.dr-leonardo.com/leonardo_design_files/leonardo_tmpls/TheSixteenth/assets/logo/logo.png"></div>
<div class="dr-nme-addr col-xs-8 col-lg-8"><span class="bok-dr-name">Select Provider</span> <select>
<option disabled="disabled" value="" selected="selected">Please select one</option>
</select> <br> <span class="bok-dr-name">Select Location</span> <select required="required" class="slct-loc col-md-10" style="margin-right: 3px; width: 165px;">
<option disabled="disabled" value="" selected="selected">Please select one</option>
<option value="[object Object]">test - 656565</option>
</select> <br> <label>Preferred Appointment Time</label> <select required="required" class="slct-loc">
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select> <select required="required" class="slct-loc">
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select> <select required="required" class="slct-loc">
<option selected="selected">AM/PM</option>
<option value="am">AM</option>
<option value="pm">PM</option>
</select></div>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-offset-1 col-xs-10 col-md-offset-1 col-md-10 calendar-bx">
<div class="col-md-8 col-md-offset-2">
<div class="dte-time-cont center-block"><label><span class="book-wk-day">Friday</span> - <span class="book-date">06/21/2024 08:35</span></label></div>
</div> <br>
<div class="row">
<div data-role="date-picker" id="datepicker" class="center-block" style="width: 270px;">
<table role="grid" style="width: 100%;">
<thead>
<tr>
<td><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><i class="glyphicon glyphicon-chevron-left"></i></button></td>
<td colspan="5"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><b>2024 June</b></button></td>
<td><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><i class="glyphicon glyphicon-chevron-right"></i></button></td>
</tr>
<tr align="center">
<td width="14.2857142857%"><small>Sun</small></td>
<td width="14.2857142857%"><small>Mon</small></td>
<td width="14.2857142857%"><small>Tue</small></td>
<td width="14.2857142857%"><small>Wed</small></td>
<td width="14.2857142857%"><small>Thu</small></td>
<td width="14.2857142857%"><small>Fri</small></td>
<td width="14.2857142857%"><small>Sat</small></td>
</tr>
</thead>
<tbody>
<tr>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">26</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">27</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">28</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">29</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">30</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">31</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">1</span></button></td>
</tr>
<tr>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">2</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">3</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">4</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">5</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">6</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">7</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">8</span></button></td>
</tr>
<tr>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">9</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">10</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">11</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">12</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">13</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">14</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">15</span></button></td>
</tr>
<tr>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">16</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">17</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">18</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">19</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">20</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-info btn-sm" style="border: none;"><span data-action="select" class="">21</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">22</span></button></td>
</tr>
<tr>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">23</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">24</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">25</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">26</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">27</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">28</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">29</span></button></td>
</tr>
<tr>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="">30</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">1</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">2</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">3</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">4</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">5</span></button></td>
<td><button data-action="select" type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span data-action="select" class="text-muted">6</span></button></td>
</tr>
</tbody>
</table>
<table role="grid" style="width: 100%; display: none;">
<thead>
<tr>
<td><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><i class="glyphicon glyphicon-chevron-left"></i></button></td>
<td colspan="4"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><b>2024</b></button></td>
<td><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><i class="glyphicon glyphicon-chevron-right"></i></button></td>
</tr>
</thead>
<tbody>
<tr>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>January</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>February</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>March</span></button></td>
</tr>
<tr>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>April</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>May</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-primary btn-sm" style="border: none;"><span>June</span></button></td>
</tr>
<tr>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>July</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>August</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>September</span></button></td>
</tr>
<tr>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>October</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>November</span></button></td>
<td colspan="2" width="33.333333%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>December</span></button></td>
</tr>
</tbody>
</table>
<table role="grid" style="width: 100%; display: none;">
<thead>
<tr>
<td><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><i class="glyphicon glyphicon-chevron-left"></i></button></td>
<td colspan="3"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><b>2020 ~ 2039</b></button></td>
<td><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><i class="glyphicon glyphicon-chevron-right"></i></button></td>
</tr>
</thead>
<tbody>
<tr>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2020</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2021</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2022</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2023</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-primary btn-sm" style="border: none;"><span>2024</span></button></td>
</tr>
<tr>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2025</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2026</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2027</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2028</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2029</span></button></td>
</tr>
<tr>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2030</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2031</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2032</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2033</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2034</span></button></td>
</tr>
<tr>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2035</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2036</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2037</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2038</span></button></td>
<td width="20%"><button type="button" class="btn btn-block btn-default btn-sm" style="border: none;"><span>2039</span></button></td>
</tr>
</tbody>
</table>
<div><br>
<div class="text-center"><button data-action="select" type="button" class="btn btn-info btn-sm">Today</button> <button data-action="select" type="button" class="btn btn-default btn-sm">Clear</button></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 appoint-right form-appoint-details">
<div class="row">
<div class="col-md-12 form-wrap">
<div class="row">
<div class="col-md-12 text-center left-date"> <span class="left-time"></span></div>
</div>
<div class="col-md-4 col-xs-12 frm-rw-spce frm-col-pad-rht"><label>First Name <span>*</span></label> <input type="text" name="FirstName" required="required"></div>
<div class="col-md-8 col-xs-12 frm-rw-spce frm-col-pad-lft"><label>Last Name <span>*</span></label> <input type="text" name="LastName" required="required"></div>
<div class="col-md-4 col-xs-12 frm-rw-spce frm-col-pad-rht"><label>Phone # <span>*</span></label> <input type="text" name="Phone" required="required"></div>
<div class="col-md-8 col-xs-12 frm-rw-spce frm-col-pad-lft"><label>Mobile Phone #</label> <input type="text" name="Phone"></div>
<div class="col-md-12 col-xs-12 frm-rw-spce"><label>Email <span>*</span></label> <input type="email" name="Email" required="required" class="form-control"></div>
<div class="col-md-4 col-sm-4 col-xs-4 frm-rw-spce frm-col-pad-rht"><label>New Patient <span>*</span></label> <select id="NewPatient" name="NewPatient" required="required" class=" form-control" style="width: 100%;">
<option value="1">Yes</option>
<option value="0">No</option>
</select></div>
<div class="col-md-8 col-sm-8 col-xs-8 frm-rw-spce frm-col-pad-lft"><label>Preferred Contact Method <span>*</span></label> <select id="preferred_contact_method" name="Preferred_Contact_Method" required="required" class=" w-full form-control">
<option selected="selected" value="">Please select one</option>
<option value="phone">Phone</option>
<option value="text">Text</option>
<option value="email">Email</option>
</select></div>
<div class="col-md-12 col-sm-12 col-xs-12 frm-rw-spce frm-col-pad-rht"><label>Type of Appointment Request</label> <select id="appointment_type" name="appointment_type" class=" w-full form-control">
<option selected="selected" value="">Please select one</option>
<option value="in-office">In-office Visit</option>
<option value="telemedicine">Telemedicine Visit</option>
</select></div>
<div class="col-md-12 col-sm-12 col-xs-12 frm-rw-spce"><label>Reason for Visit</label> <textarea name="Message"></textarea></div>
<div class="row">
<div class="col-md-12 col-sm-12 col-xs-12"></div>
</div>
<div class="row">
<div class="col-md-offset-4 col-md-8 col-sm-8 col-xs-8"><button type="submit" class="btn-rqust-app"> Request Appointment</button></div>
</div> <br>
</div>
</div>
</div>
</form>Text Content
test Your Health is Our Priority 656565, 656 56, Kentucky 65 565-656-56 * HOME * ABOUT * STAFF * HEALTH INFORMATION * LOCATION * PATIENT PORTAL CONNECT WITH OUR PHARMACISTS Health Information LEARN MORE ABOUT OUR SERVICES Health Information ACCESS THE CARE YOU NEED Health Information CONNECT WITH OUR PHARMACISTS Health Information LEARN MORE ABOUT OUR SERVICES Health Information ACCESS THE CARE YOU NEED Health Information CONNECT WITH OUR PHARMACISTS Health Information LEARN MORE ABOUT OUR SERVICES Health Information ACCESS THE CARE YOU NEED Health Information WELCOME TO TEST Thank you for choosing test. Our pharmacy is committed to providing you with a superior level of care in a friendly and personalized environment. Our pharmacy is dedicated to providing health care for our customers, with pleasant surroundings in a state-of-the-art facility. We are very proud of the relationships that we have established with our customers. The pharmacists and staff at test are focused on maintaining your trust and confidence. We are especially honored that our customers have referred so many of their friends and relatives to our pharmacy. We look forward to making lasting relationships with every customer we meet. SERVICES Utilizing the latest advances in medicine combined with state-of-the-art techniques, our specialized services include: * Compounding * Hormone Therapy * Vaccine * Infusion * Diabetes Services * Specialty Medications * Pharmacy Consultations To learn more about the services we provide, please call us today at one of our locations. OUR STAFF LOCATIONS TEST 656565 656 56,Kentucky 65 Phone: 565-656-56 Mon: 9:00 - 5:00 Tue: 9:00 - 5:00 Wed: 9:00 - 5:00 Thu: 9:00 - 5:00 Fri: 9:00 - 5:00 Sat: 9:00 - 5:00 Sun: 9:00 - 5:00 LEARN MORE Add your custom content here... Back to top * Terms of Use * Notice of Privacy Practices * Website Privacy Policy * Health Information Copyright © 2023 by test and DaVinci Interactive Webservices, Inc. All Rights Reserved. × SCHEDULE AN APPOINTMENT Select Provider Please select one Select Location Please select one test - 656565 Preferred Appointment Time 123456789101112 00153045 AM/PM AM PM Friday - 06/21/2024 08:35 2024 June SunMonTueWedThuFriSat 262728293031123456789101112131415161718192021222324252627282930123456 2024 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2020 ~ 2039 20202021202220232024202520262027202820292030203120322033203420352036203720382039 Today Clear First Name * Last Name * Phone # * Mobile Phone # Email * New Patient * Yes No Preferred Contact Method * Please select one Phone Text Email Type of Appointment Request Please select one In-office Visit Telemedicine Visit Reason for Visit Request Appointment