www.puskesmas.sandemo.web.id Open in urlscan Pro
202.10.42.44  Public Scan

Form analysis
2 forms found in the DOM

POST https://www.puskesmas.sandemo.web.id/login/login_proses

<form class="form-horizontal mt-3" id="loginform" action="https://www.puskesmas.sandemo.web.id/login/login_proses" method="post">
  <div class="input-group mb-3">
    <div class="input-group-prepend">
      <span class="input-group-text" id="basic-addon1"><i class="ti-user"></i></span>
    </div>
    <input type="text" class="form-control form-control-lg" placeholder="Username" aria-label="Username" aria-describedby="basic-addon1" name="username">
  </div>
  <div class="input-group mb-3">
    <div class="input-group-prepend">
      <span class="input-group-text" id="basic-addon2"><i class="ti-pencil"></i></span>
    </div>
    <input type="password" class="form-control form-control-lg" placeholder="Password" aria-label="Password" aria-describedby="basic-addon1" name="password">
  </div>
  <div class="form-group row">
    <div class="col-md-12">
      <div class="custom-control custom-checkbox">
        <input type="checkbox" class="custom-control-input" id="customCheck1">
        <label class="custom-control-label" for="customCheck1">Remember me</label>
        <a href="" class="text-dark float-right"><i class="fa fa-lock mr-1"></i> Forgot pwd?</a>
      </div>
    </div>
  </div>
  <div class="form-group text-center">
    <div class="col-xs-12 pb-3">
      <button class="btn btn-block btn-lg btn-info" type="submit">Log In</button>
    </div>
  </div>
  <div class="mb-3 mb-0 mt-2">
    <div class="col-sm-12 text-center"> Don't have an account? <a href="javascript:void(0)" id="to-recover" class="text-info ms-1"><b>Sign Up</b></a>
    </div>
  </div>
</form>

POST https://www.puskesmas.sandemo.web.id/login/register_proses

<form class="col-12" action="https://www.puskesmas.sandemo.web.id/login/register_proses" method="post">
  <!-- email -->
  <div class="form-group row">
    <label for="nama_user" class="col-sm-3 control-label col-form-label">Nama</label>
    <div class="col-sm-9">
      <input class="form-control" type="text" placeholder="Nama" id="nama_user" name="nama_user" required="">
    </div>
  </div>
  <div class="form-group row">
    <label for="username" class="col-sm-3 control-label col-form-label">Username</label>
    <div class="col-sm-9">
      <input class="form-control" type="text" placeholder="Username" id="username" name="username" required="">
    </div>
  </div>
  <div class="form-group row">
    <label for="email_user" class="col-sm-3 control-label col-form-label">Email</label>
    <div class="col-sm-9">
      <input class="form-control" type="email" placeholder="nama@email.com" id="email_user" name="email_user" required="">
    </div>
  </div>
  <div class="form-group row">
    <label for="password" class="col-sm-3 control-label col-form-label">Password</label>
    <div class="col-sm-9">
      <input class="form-control" type="password" id="password" name="password" required="">
    </div>
  </div>
  <div class="form-group row">
    <label for="tempat_lahir" class="col-sm-3 control-label col-form-label">Tempat Lahir</label>
    <div class="col-sm-9">
      <input class="form-control" type="text" placeholder="Tempat Lahir" id="tempat_lahir" name="tempat_lahir" required="">
    </div>
  </div>
  <div class="form-group row">
    <label for="tgl_lahir" class="col-sm-3 control-label col-form-label">Tanggal Lahir</label>
    <div class="col-sm-9">
      <input class="form-control" type="date" id="tgl_lahir" name="tgl_lahir" required="">
    </div>
  </div>
  <div class="form-group row">
    <label for="jenis_kelamin" class="col-sm-3 control-label col-form-label">Jenis Kelamin</label>
    <div class="col-sm-9">
      <select class="select2 form-control" style="width: 100%;" name="jenis_kelamin" id="jenis_kelamin" required="">
        <option value="Laki Laki">Laki Laki</option>
        <option value="Perempuan">Perempuan</option>
      </select>
    </div>
  </div>
  <div class="form-group row">
    <label for="alamat" class="col-sm-3 control-label col-form-label">Alamat</label>
    <div class="col-sm-9">
      <textarea class="form-control" id="alamat" name="alamat" required=""></textarea>
    </div>
  </div>
  <div class="form-group row">
    <label for="no_hp" class="col-sm-3 control-label col-form-label">No Hp</label>
    <div class="col-sm-9">
      <input class="form-control" type="number" id="no_hp" name="no_hp" required="">
    </div>
  </div>
  <div class="form-group text-center">
    <div class="col-xs-12 p-b-20">
      <button class="btn btn-block btn-lg btn-info" type="submit">Register</button>
    </div>
  </div>
  <!-- pwd -->
  <div class="row m-t-20">
    <div class="col-12">
      <input type="checkbox" class="custom-control-input" id="customCheck1">
      <label>Anda Sudah Punya Akun ? Silahkan Klik</label>
      <a href="javascript:void(0)" id="to-recover-2" class="text-dark float-right"><i class="fa fa-registered m-r-5"></i> Login</a><br><br><br>
    </div>
  </div>
</form>

Text Content

APLIKASI PUSKESMAS

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APLIKASI PUSKESMAS

REGISTER

Nama

Username

Email

Password

Tempat Lahir

Tanggal Lahir

Jenis Kelamin
Laki Laki Perempuan
Alamat

No Hp

Register
Anda Sudah Punya Akun ? Silahkan Klik Login