acnvirtual.org
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Submitted URL: https://acnvirtual.org/
Effective URL: https://acnvirtual.org/landing.htm
Submission: On July 24 via api from US — Scanned from DE
Effective URL: https://acnvirtual.org/landing.htm
Submission: On July 24 via api from US — Scanned from DE
Form analysis
1 forms found in the DOMName: enrollmentForm — POST /landing.htm
<form id="enrollmentForm" name="enrollmentForm" novalidate="true" action="/landing.htm" method="POST" autocomplete="off"><input type="hidden" id="csrfToken" name="csrfToken" value="fLAhRH9wSIthgHxYQ7MyqQvx">
<div class="enrollmentFormContent">
<div id="nameFields" class="enrollmentFieldRow">
<div class="has-float-label smaller ">
<input id="firstName" name="firstName" class="nameField float_input firstOnly botton-border-only" placeholder="First Name*" aria-label="Required Field First Name" required="true" value="" maxlength="255" autocomplete="off">
<label for="firstName">First Name*</label>
</div>
<div class="has-float-label">
<input id="middleInitial" name="middleInitial" class="nameField float_input middleInitial" placeholder="MI" aria-label="Required Field Middle Name" required="false" value="" maxlength="1" autocomplete="off">
<label for="middleInitial">MI</label>
</div>
<div class="has-float-label lastOnlyContainer smaller">
<input id="lastName" name="lastName" class="nameField float_input lastOnly botton-border-only" placeholder="Last Name*" aria-label="Required Field Last Name" required="true" value="" maxlength="255" autocomplete="off">
<label for="lastName">Last Name*</label>
</div>
</div>
<div class="clearFix"></div>
<div id="nameErrors">
<div aria-atomic="true" class="form_error_container">
<div class="error" id="firstName.errors" style="display: none;"></div>
</div>
<div aria-atomic="true" class="form_error_container">
<div class="error" id="middleInitial.errors" style="display: none;"></div>
</div>
<div aria-atomic="true" class="form_error_container">
<div class="error" id="lastName.errors" style="display: none;"></div>
</div>
</div>
<div id="emailFields" class="enrollmentFieldRow">
<div class="has-float-label">
<input id="emailAddress" name="emailAddress" class="fullWidth botton-border-only float_input" placeholder="Email*" required="true" value="" autocomplete="off">
<label for="emailAddress">Email*</label>
<div>
<div aria-atomic="true" class="form_error_container">
<div class="error" id="emailAddress.errors" style="display: none;"></div>
</div>
</div>
</div>
<div class="has-float-label">
<input id="emailAddress2" name="emailAddress2" class="fullWidth botton-border-only float_input" placeholder="Confirm Email*" required="true" value="" autocomplete="off">
<label for="emailAddress2">Confirm Email*</label>
<div>
<div aria-atomic="true" class="form_error_container">
<div class="error" id="emailAddress2.errors" style="display: none;"></div>
</div>
</div>
</div>
</div>
<div id="passwordField" class="enrollmentFieldRow">
<div class="has-float-label">
<input name="password1" type="password" placeholder="Password*" id="password1" class="float_input fullWidth botton-border-only" aria-describedby="validationCriteria" required="true">
<label for="emailAddress2">Password*</label>
</div>
<div id="failedPwdReq" class="error hideme"> Password does not meet requirements </div>
</div>
<div id="disclaimerField">
<input id="disclaimerIds" name="disclaimerIds" type="hidden" value="aZGDfJGKMAfVGFCdbANaSGfZfbMASSHYfMWPRARIKWRQBAETIKKbGbSWSLIWNeYZLZHeRQJYABHeC">
<input type="checkbox" name="disclaimerAccept" id="disclaimerAccept" aria-label="Checkbox i agree to these Terms of Use." required="">
<label class="modernLabel14" id="disclaimerPromptLabel"> I agree to the following:</label>
<a class="modernLabel14 link" id="tosLink" href="#">
Terms of Use*
</a>
<div>
<div aria-atomic="true" class="form_error_container">
<div class="error" id="disclaimerAccept.errors" style="display: none;"></div>
</div>
</div>
</div>
</div>
<div>
<button id="submitBtn" class="wcagGreen greenCtBtn flatBtn xlargeCtBtn dijitButton bigSplashButton" type="submit" dojoattachevent="ondijitclick:_onClick" dojoattachpoint="focusNode,titleNode" widgetid="submitBtn" style="user-select: none;">
<span class="iconRel">
<span class="dijitInline iconNode dijitNoIcon" dojoattachpoint="iconNode"></span>
<span class="dijitButtonText" dojoattachpoint="containerNode"> Sign Up </span>
</span>
</button>
</div>
<div class="loginLinkContainer">
<a tabindex="0" href="https://acnvirtual.org/loginConsumer.htm" class="link loginLink">
I already have an account, Log In
</a>
</div>
</form>
Text Content
* Log In | * Test Computer | * Provider Login SEE A PROVIDER NOW! -------------------------------------------------------------------------------- Providing national telemedicine coverage, simply log in to connect with a board-certified provider in your area. Please call 866-880-8330 if you need assistance. If you are experiencing a life-threatening emergency, please call 911 SIGN UP First Name* MI Last Name* Email* Confirm Email* Password* Password does not meet requirements I agree to the following: Terms of Use* Sign Up I already have an account, Log In ©2018 Providence Health & Services ©2018 Swedish Medical Center. All Rights Reserved. * Terms of Use * Privacy Policy * Contact Us