www.circlehealthgroup.co.uk Open in urlscan Pro
2606:4700:10::6816:1083  Public Scan

Submitted URL: https://www.bmihealthcare.co.uk/online-payments
Effective URL: https://www.circlehealthgroup.co.uk/pay-my-bill
Submission Tags: falconsandbox
Submission: On March 07 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST /api/sitecore/OnlinePayments/OnlinePayments

<form action="/api/sitecore/OnlinePayments/OnlinePayments" method="post" class="f-container f-container-center"><!---->
  <div class="online-payment--content">
    <div class="appointment"><!---->
      <div class="appointment-form">
        <p class="f-margin-remove">* required field</p>
        <div class="f-grid f-grid-width-large-1-2">
          <div>
            <div class="form-row f-width-medium-2-3 f-width-large-1-1">
              <div class="floaty-label"><select autocomplete="honorific-prefix" id="paying" name="OnlinePayment.PaymentType" required="required">
                  <option value="patient">Patient</option>
                  <option value="cardholder">BMI card holder</option>
                  <option value="consultant">Consultant</option>
                </select> <label for="paying" class="">I'm paying as a</label></div> <!---->
            </div>
            <div class="form-row form-row--inline">
              <div class="title floaty-label"><select autocomplete="honorific-prefix" id="title" name="OnlinePayment.PersonalInfo.Title" required="required">
                  <option value=""></option>
                  <option value="Dr">Dr</option>
                  <option value="Doctor">Doctor</option>
                  <option value="Miss">Miss</option>
                  <option value="Mr">Mr</option>
                  <option value="Mrs">Mrs</option>
                  <option value="Ms">Ms</option>
                  <option value="Prof">Prof</option>
                  <option value="Professor">Professor</option>
                </select> <label for="title" class="">Title</label></div>
              <div class="first-name floaty-label"><input autocomplete="given-name" id="first-name" name="OnlinePayment.PersonalInfo.FirstName" placeholder=" " required="required" type="text" value="" class=""> <label for="first-name" class="">First
                  name</label></div>
            </div>
            <div class="form-row floaty-label"><input autocomplete="family-name" id="surname" name="OnlinePayment.PersonalInfo.Surname" placeholder=" " required="required" type="text" value="" class=""> <label for="surname" class="">Surname</label>
            </div>
            <div class="form-row"><label>Patient date of birth</label>
              <div class="form-row--inline">
                <div class="dob-field floaty-label"><select autocomplete="bday-day" id="dobday" name="OnlinePayment.PersonalInfo.DOBDay" required="required" title="Date of birth day">
                    <option value=""></option>
                    <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>
                    <option value="13">13</option>
                    <option value="14">14</option>
                    <option value="15">15</option>
                    <option value="16">16</option>
                    <option value="17">17</option>
                    <option value="18">18</option>
                    <option value="19">19</option>
                    <option value="20">20</option>
                    <option value="21">21</option>
                    <option value="22">22</option>
                    <option value="23">23</option>
                    <option value="24">24</option>
                    <option value="25">25</option>
                    <option value="26">26</option>
                    <option value="27">27</option>
                    <option value="28">28</option>
                    <option value="29">29</option>
                    <option value="30">30</option>
                    <option value="31">31</option>
                  </select> <label for="dobday" class="">Day</label></div>
                <div class="dob-field floaty-label"><select autocomplete="bday-month" id="dobmonth" name="OnlinePayment.PersonalInfo.DOBMonth" required="required" title="Date of birth month">
                    <option value="1">January</option>
                    <option value="2">February</option>
                    <option value="3">March</option>
                    <option value="4">April</option>
                    <option value="5">May</option>
                    <option value="6">June</option>
                    <option value="7">July</option>
                    <option value="8">August</option>
                    <option value="9">September</option>
                    <option value="10">October</option>
                    <option value="11">November</option>
                    <option value="12">December</option>
                  </select> <label for="dobmonth" class="">Month</label></div>
                <div class="dob-field floaty-label"><select autocomplete="bday-year" id="dobyear" name="OnlinePayment.PersonalInfo.DOBYear" required="required" title="Date of birth year">
                    <option value=""></option>
                    <option value="2022">2022</option>
                    <option value="2021">2021</option>
                    <option value="2020">2020</option>
                    <option value="2019">2019</option>
                    <option value="2018">2018</option>
                    <option value="2017">2017</option>
                    <option value="2016">2016</option>
                    <option value="2015">2015</option>
                    <option value="2014">2014</option>
                    <option value="2013">2013</option>
                    <option value="2012">2012</option>
                    <option value="2011">2011</option>
                    <option value="2010">2010</option>
                    <option value="2009">2009</option>
                    <option value="2008">2008</option>
                    <option value="2007">2007</option>
                    <option value="2006">2006</option>
                    <option value="2005">2005</option>
                    <option value="2004">2004</option>
                    <option value="2003">2003</option>
                    <option value="2002">2002</option>
                    <option value="2001">2001</option>
                    <option value="2000">2000</option>
                    <option value="1999">1999</option>
                    <option value="1998">1998</option>
                    <option value="1997">1997</option>
                    <option value="1996">1996</option>
                    <option value="1995">1995</option>
                    <option value="1994">1994</option>
                    <option value="1993">1993</option>
                    <option value="1992">1992</option>
                    <option value="1991">1991</option>
                    <option value="1990">1990</option>
                    <option value="1989">1989</option>
                    <option value="1988">1988</option>
                    <option value="1987">1987</option>
                    <option value="1986">1986</option>
                    <option value="1985">1985</option>
                    <option value="1984">1984</option>
                    <option value="1983">1983</option>
                    <option value="1982">1982</option>
                    <option value="1981">1981</option>
                    <option value="1980">1980</option>
                    <option value="1979">1979</option>
                    <option value="1978">1978</option>
                    <option value="1977">1977</option>
                    <option value="1976">1976</option>
                    <option value="1975">1975</option>
                    <option value="1974">1974</option>
                    <option value="1973">1973</option>
                    <option value="1972">1972</option>
                    <option value="1971">1971</option>
                    <option value="1970">1970</option>
                    <option value="1969">1969</option>
                    <option value="1968">1968</option>
                    <option value="1967">1967</option>
                    <option value="1966">1966</option>
                    <option value="1965">1965</option>
                    <option value="1964">1964</option>
                    <option value="1963">1963</option>
                    <option value="1962">1962</option>
                    <option value="1961">1961</option>
                    <option value="1960">1960</option>
                    <option value="1959">1959</option>
                    <option value="1958">1958</option>
                    <option value="1957">1957</option>
                    <option value="1956">1956</option>
                    <option value="1955">1955</option>
                    <option value="1954">1954</option>
                    <option value="1953">1953</option>
                    <option value="1952">1952</option>
                    <option value="1951">1951</option>
                    <option value="1950">1950</option>
                    <option value="1949">1949</option>
                    <option value="1948">1948</option>
                    <option value="1947">1947</option>
                    <option value="1946">1946</option>
                    <option value="1945">1945</option>
                    <option value="1944">1944</option>
                    <option value="1943">1943</option>
                    <option value="1942">1942</option>
                    <option value="1941">1941</option>
                    <option value="1940">1940</option>
                    <option value="1939">1939</option>
                    <option value="1938">1938</option>
                    <option value="1937">1937</option>
                    <option value="1936">1936</option>
                    <option value="1935">1935</option>
                    <option value="1934">1934</option>
                    <option value="1933">1933</option>
                    <option value="1932">1932</option>
                    <option value="1931">1931</option>
                    <option value="1930">1930</option>
                    <option value="1929">1929</option>
                    <option value="1928">1928</option>
                    <option value="1927">1927</option>
                    <option value="1926">1926</option>
                    <option value="1925">1925</option>
                    <option value="1924">1924</option>
                    <option value="1923">1923</option>
                    <option value="1922">1922</option>
                    <option value="1921">1921</option>
                    <option value="1920">1920</option>
                    <option value="1919">1919</option>
                    <option value="1918">1918</option>
                    <option value="1917">1917</option>
                    <option value="1916">1916</option>
                    <option value="1915">1915</option>
                    <option value="1914">1914</option>
                    <option value="1913">1913</option>
                    <option value="1912">1912</option>
                    <option value="1911">1911</option>
                    <option value="1910">1910</option>
                    <option value="1909">1909</option>
                    <option value="1908">1908</option>
                    <option value="1907">1907</option>
                    <option value="1906">1906</option>
                    <option value="1905">1905</option>
                    <option value="1904">1904</option>
                    <option value="1903">1903</option>
                    <option value="1902">1902</option>
                  </select> <label for="dobyear" class="">Year</label></div>
              </div>
            </div>
            <div class="form-row floaty-label"><input autocomplete="email" id="email" name="OnlinePayment.PersonalInfo.Email" placeholder=" " required="required" type="email" value="" class=""> <label for="email" class="">Email address</label></div>
            <div class="form-row form-row--inline">
              <div class="address floaty-label"><input autocomplete="off" id="postcode" name="OnlinePayment.Address.AddressSelector" placeholder=" " type="text" value="" class=""> <label for="postcode" class="">Start typing your address to
                  search</label></div>
            </div>
            <div class="address-select js-address-select" style="display: none;"></div>
            <div class="address-final-block js-address-final" style="display: none;">
              <p></p>
            </div> <input id="OnlinePayment_Address_AddressLine1" name="OnlinePayment.Address.AddressLine1" type="hidden" value=""> <input id="OnlinePayment_Address_AddressLine2" name="OnlinePayment.Address.AddressLine2" type="hidden" value="">
            <input id="OnlinePayment_Address_City" name="OnlinePayment.Address.City" type="hidden" value=""> <input id="OnlinePayment_Address_Postcode" name="OnlinePayment.Address.Postcode" type="hidden" value=""> <input
              id="OnlinePayment_Address_Country" name="OnlinePayment.Address.Country" type="hidden" value="">
          </div>
          <div>
            <div class="form-row floaty-label" style="display: none;"><!----></div>
            <div class="form-row">
              <div class="floaty-label f-autocomplete f-width-1-1"><input required="required" id="hospital" name="OnlinePayment.Hospital" placeholder=" " type="text" value="" class="f-width-1-1 js-hospital-autocomplete" autocomplete="off"> <label
                  for="hospital">Hospital attended*</label>
                <div class="f-dropdown" aria-expanded="false"></div>
              </div>
            </div>
            <div class="form-row floaty-label" style="display: none;"><!----></div>
            <div class="form-row form-row--help">
              <div class="floaty-label"><input id="accountNumber" name="OnlinePayment.AccountNumber" placeholder=" " required="required" type="text" value="" class="f-width-1-1"> <label for="accountNumber">Account number or our ref*</label></div>
              <p tabindex="0" class="help-tooltip"><svg width="16" height="16">
                  <use xlink:href="#icon-info-alt"></use>
                </svg> <span class="help-tooltip--content">Your account number can be found on your invoice.</span></p>
            </div>
            <div class="form-row form-row--help">
              <div class="floaty-label"><input id="invoiceNumber" name="OnlinePayment.InvoiceNumber" placeholder=" " type="text" value="" class="f-width-1-1"> <label for="invoiceNumber">Invoice number (if known)</label></div>
              <p tabindex="0" class="help-tooltip"><svg width="16" height="16">
                  <use xlink:href="#icon-info-alt"></use>
                </svg> <span class="help-tooltip--content">Your invoice number can be found on your invoice.</span></p>
            </div>
            <div class="form-row floaty-label"><select autocomplete="honorific-prefix" id="cardType" name="OnlinePayment.CardType" required="required">
                <option value=""></option>
                <option value="AmericanExpress">American Express</option>
                <option value="JCB">JCB</option>
                <option value="Maestro">Maestro</option>
                <option value="MastercardCredit">Mastercard Credit</option>
                <option value="MasterCard">Mastercard Debit</option>
                <option value="Visa">Visa Credit</option>
                <option value="Visa">Visa Debit</option>
              </select> <label for="cardType" class="">Card type*</label></div>
            <div class="form-row label-as-input"><label> Same address as billing <input type="checkbox" name="billingSame"> Yes </label></div> <!----> <!----> <!----> <input id="OnlinePayment_Address_BillingAddressLine1"
              name="OnlinePayment.Address.BillingAddressLine1" type="hidden" value=""> <input id="OnlinePayment_Address_BillingAddressLine2" name="OnlinePayment.Address.BillingAddressLine2" type="hidden" value=""> <input
              id="OnlinePayment_Address_BillingCity" name="OnlinePayment.Address.BillingCity" type="hidden" value=""> <input id="OnlinePayment_Address_BillingPostcode" name="OnlinePayment.Address.BillingPostcode" type="hidden" value=""> <input
              id="OnlinePayment_Address_BillingCountry" name="OnlinePayment.Address.BillingCountry" type="hidden" value="">
            <div class="form-row floaty-label payment-amount"><input id="paymentAmount" name="OnlinePayment.PaymentAmount" placeholder=" " required="required" type="text" value="" class="f-width-1-1"> <label for="paymentAmount">Payment
                amount*</label></div>
            <div class="form-row floaty-label"><button type="button" class="f-btn f-btn-xlarge f-btn-primary f-btn--next">Proceed to payment</button> <button id="submit" class="f-hidden">Proceed to payment</button>
              <div id="recaptcha" class="g-recaptcha">
                <div class="grecaptcha-badge" data-style="bottomright"
                  style="width: 256px; height: 60px; display: block; transition: right 0.3s ease 0s; position: fixed; bottom: 14px; right: -186px; box-shadow: gray 0px 0px 5px; border-radius: 2px; overflow: hidden;">
                  <div class="grecaptcha-logo"><iframe title="reCAPTCHA"
                      src="https://www.google.com/recaptcha/api2/anchor?ar=1&amp;k=6LcTq9sUAAAAAPQ7h6Kp7R1SUIGJ_6vyvRw-pA1K&amp;co=aHR0cHM6Ly93d3cuY2lyY2xlaGVhbHRoZ3JvdXAuY28udWs6NDQz&amp;hl=de&amp;v=_exWVY_hlNJJl2Abm8pI9i1L&amp;size=invisible&amp;badge=bottomright&amp;cb=spib2bekaz2y"
                      width="256" height="60" role="presentation" name="a-uhv589cli9xe" frameborder="0" scrolling="no"
                      sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
                  <div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
                    style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
                </div><iframe style="display: none;"></iframe>
              </div> <input id="recaptcha-key" name="CaptchaSiteKey" type="hidden" value="6LcTq9sUAAAAAPQ7h6Kp7R1SUIGJ_6vyvRw-pA1K"> <input id="hospitalId" name="OnlinePayment.HospitalId" type="hidden" value="" class="js-autocomplete-hospital-id">
              <input id="ContextItemGuid" name="ContextItemGuid" type="hidden" value="58ed6318-d78c-4839-9f33-c672b4ff8078">
            </div>
          </div>
        </div>
      </div>
    </div>
  </div>
</form>

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