my.wellspan.org Open in urlscan Pro
205.172.187.226  Public Scan

Form analysis
1 forms found in the DOM

POST /MyWellSpan/accesscheck.asp

<form autocomplete="off" method="post" action="/MyWellSpan/accesscheck.asp" id="signupForm" csp-guid-submit="5EC22BE754454AD59AB310D4F9950131">
  <div class="formcontents">
    <div class="hidden"><input type="hidden" class="hidden" name="sec_token" value="C3311CF0E7304368818476431094C152" autocomplete="off"></div>
    <div class="hidden"><input type="hidden" class="hidden" name="instactsignuptoken" value="0AA0F270EE1646D9A6B309D0DEFBB3C3" autocomplete="off"></div>
    <div id="locale_container" class="prelogin">
      <a href="/MyWellSpan/accesscheck.asp?InstAct=WP-24sp-2FplvUufaXfEFo2dxxa9eCLmDhbFeSrakaandmf-2BnM-3D-24KXLiWkovqBHzSuPpCbgY4Ei51YJrjnNFYTuqSOH-2BZZU-3D&amp;lang=espanol" csp-guid-click="82B22DBEB19E42D38DBFFBD99947A156"><span class="localename">Ver en Español</span><abbr class="abbreviatedname" title="Ver en Español">Esp</abbr></a>
    </div>
    <div class="title">
      <h1 class="header">MyWellSpan Signup</h1>
      <div id="assistiveicons"><img class="assistiveicon" alt="" src="/MyWellSpan/en-US/images/space.gif"></div>
    </div><input type="hidden" class="hidden" name="instactcode" value="SzAYWAHIKJzohWSrufanzAXX" autocomplete="off"><input type="hidden" class="hidden" name="instactqueryparam"
      value="WP-24sp-2FplvUufaXfEFo2dxxa9eCLmDhbFeSrakaandmf-2BnM-3D-24KXLiWkovqBHzSuPpCbgY4Ei51YJrjnNFYTuqSOH-2BZZU-3D" autocomplete="off">
    <div id="loginDiv">
      <div id="signuperror" class="alert signUpFieldError"></div>
      <div class="formsection">
        <label for="login">MyWellSpan username</label><input class="jsreq" type="text" id="login" name="Login" value="" maxlength="128" autocorrect="off" autocomplete="off">
      </div>
    </div>
    <div id="Loginerror" class="alert signUpFieldError"></div>
    <div id="passwordDiv">
      <div id="passwordFieldDiv" class="formsection">
        <label for="Password" id="PasswordLabel"> <span class="label">Create password</span>
        </label><a href="#" id="pwdButton"><img id="pwdButtonImg" src="/MyWellSpan/en-US/images/info_grey.png" alt="Screen readers: use read next line command to hear password guidelines." title="" csp-guid-click="A802C1E7A8CF42BBB1B0E3EAA60821F4"></a><input
          type="password" name="Password" id="Password" csp-guid-keyup="A06A7235547D40528069403565958BB8" csp-guid-blur="03C3A7605D0E4956A9DF6FEEE8A30471" width="90%" autocomplete="off"><input class="hidden" type="text" name="PasswordText"
          id="PasswordText" csp-guid-keyup="A06A7235547D40528069403565958BB8" csp-guid-blur="03C3A7605D0E4956A9DF6FEEE8A30471" width="90%" autocorrect="off" autocomplete="off">
        <div id="pwdGuidelines">
          <div id="pwdInstructions" class="hidden">Must contain at least: <ul>
              <li>One lowercase letter.</li>
              <li>One uppercase letter.</li>
              <li>One number.</li>
              <li>One special character.</li>
            </ul>
          </div>
        </div><button type="button" id="showPwd" name="showPwd" csp-guid-click="B4C52F473FB34719BD3DAC72FF136E41" autocomplete="off">Show</button>
      </div>
      <div id="LoginPassworderror" class="alert signUpFieldError">
      </div>
    </div>
    <div id="passwordStrength">
      <div id="pwdStrLabel">Password strength<br style="display: none;"></div>
      <div id="pwdStrengthDiv0"></div>
      <div id="pwdStrengthDiv50"></div>
      <div id="pwdStrengthDiv75"></div>
      <div id="pwdStrengthDiv100"></div>
      <div id="passwordStrengthWords"></div>
    </div>
    <div id="verificationItemsDiv">
      <script nonce="" type="text/javascript">
        var sEmptyFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your date of birth."),
          sInvalidFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid date of birth.");
      </script>
      <fieldset class="formsection">
        <legend class="compact header small">Date of birth</legend><label class="clearlabel inlinelabel" for="dob1">Month of birth</label>
        <div class="segment2"><input class="jsreq" type="number" name="dob" id="dob1" maxlength="2" value="" csp-guid-keyup="CBAE010088424822B2F7C0052FF975FD" csp-guid-keydown="1898C73024A940E2B0910C9E8794A052"
            csp-guid-blur="ECACD8EC6F0D4127A2E5FE4F479B8561" csp-guid-click="537F7F98459D478A8E64DD2E79B7A35A" csp-guid-keypress="3C7E933184794F5E8FB9C38C44777CCB" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">mm</div>
        </div><span class="separator subtle" aria-hidden="true">/</span><label class="clearlabel inlinelabel" for="dob2">Day of birth</label>
        <div class="segment2"><input class="jsreq" type="number" name="dob" id="dob2" maxlength="2" value="" csp-guid-keyup="6CEEDB41ACA74104B467F90F46FB00C5" csp-guid-keydown="615F24FDD9374B08945439E205CDC51E"
            csp-guid-blur="1E14CCDCBF4F4B258600CA7FCCF4006D" csp-guid-click="D12D60ADF4BA4736B5579831C22628DF" csp-guid-keypress="ACDCA909F08C41F9AC368F2710E30195" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">dd</div>
        </div><span class="separator subtle" aria-hidden="true">/</span><label class="clearlabel inlinelabel" for="dob3">Year of birth</label>
        <div class="segment4"><input class="jsreq" type="number" name="dob" id="dob3" maxlength="4" value="" csp-guid-keyup="B6FFE7A5DBD74E318587A2A7FF965CB3" csp-guid-keydown="9684F6075D37441EA9BA04A75F41F3B6"
            csp-guid-blur="800710E1E65843E3B1D8C46A575FC1CB" csp-guid-click="B3F818DA6FE44067A25B046FF6CA2FD9" csp-guid-keypress="43E80051166C407ABF0AB6A3B1EA73A8" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">yyyy</div>
        </div>
        <div id="doberror" class="signUpFieldError"></div>
      </fieldset>
      <div class="formsection"><label for="ssn4" class="header small compact">Social Security number (last 4 digits)</label>
        <script nonce="" type="text/javascript">
          var sEmptyFieldErrorssn4 = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter the last 4 digits of your Social Security number.");
          var sInvalidFieldErrorssn4 = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid last 4 digits of Social Security number.");
        </script>
        <div class="segment4"><input class="jsreq" type="password" name="ssn4" id="ssn4" value="" maxlength="4" csp-guid-keyup="1BD50C40E89840A29D9CC8AB5467E862" csp-guid-blur="5D40F6E9177A49DCB0CF0B0D5335770C" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">nnnn</div>
        </div>
        <div id="ssn4error" class="signUpFieldError"></div>
      </div>
    </div>
    <div id="secResponsesDiv"></div> <input class="button jsreq completeworkflow" type="submit" name="instactsignup" id="instactsignup" value="Submit" title="" autocomplete="off">
  </div>
</form>

Text Content

Ver en EspañolEsp


MYWELLSPAN SIGNUP


MyWellSpan username

Create password
Must contain at least:
 * One lowercase letter.
 * One uppercase letter.
 * One number.
 * One special character.

Show

Password strength






Date of birthMonth of birth
mm
/Day of birth
dd
/Year of birth
yyyy

Social Security number (last 4 digits)
nnnn