mdxideal.claimax.ae Open in urlscan Pro
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1 forms found in the DOM

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<form method="post" action="#" id="Form1" class="signup-form text-center">
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  <fieldset>
    <h2>Sign in to <span class="clr">Claimax</span></h2>
    <p>Enter your details below.</p>
    <div class="form-group">
      <input name="txt_username" type="text" id="txt_username" class="form-control" style="color:#000" placeholder="Username">
      <input name="txt_password" type="password" id="txt_password" class="form-control" style="color:#000" placeholder="Password">
      <table id="RadioButtonList1" align="center" style="font-size:Medium;">
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          <tr>
            <td><input id="RadioButtonList1_0" type="radio" name="RadioButtonList1" value="Clinic" checked="checked"><label for="RadioButtonList1_0">Clinic</label></td>
            <td><input id="RadioButtonList1_1" type="radio" name="RadioButtonList1" value="Pharmacy"><label for="RadioButtonList1_1">Pharmacy</label></td>
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  <input name="txt_longtitude" type="text" id="txt_longtitude" class="input100" style="display:none;">
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Text Content

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