s8.cesoft.com.au Open in urlscan Pro
3.24.64.66  Public Scan

Form analysis
1 forms found in the DOM

POST

<form class="form_table ng-pristine ng-valid" data-integrapay="PaymentForm" method="POST"> <input class="form_input" data-integrapay="BusinessKey" type="hidden" value="EE04FD10-21B2-40EC-B538-7B9C08E38AE0" autocomplete="off"> <input
    class="form_input" data-integrapay="CardToken" name="CardToken" type="hidden" id="integra-card-token" autocomplete="off">
  <div class="form_row"> <label class="form_label" for="CardName">Cardholder name:</label> <input class="form_input_with_border" data-integrapay="CardName" id="CardName" name="CardName" type="text" autocomplete="off"> </div>
  <div class="form_row"> <label class="form_label" for="CardNumber">Card number:</label> <input class="form_input_with_border" data-integrapay="CardNumber" id="CardNumber" type="text" autocomplete="off"> </div>
  <div class="form_row"> <label class="form_label" for="CardExpiryMonth">Expiry date:</label> <select class="form_input" data-integrapay="CardExpiryMonth" id="CardExpiryMonth" name="CardExpiryMonth">
      <option class="form_option" value="01">Jan</option>
      <option class="form_option" value="02">Feb</option>
      <option class="form_option" value="03">Mar</option>
      <option class="form_option" value="04">Apr</option>
      <option class="form_option" value="05">May</option>
      <option class="form_option" value="06">Jun</option>
      <option class="form_option" value="07">Jul</option>
      <option class="form_option" value="08">Aug</option>
      <option class="form_option" value="09">Sep</option>
      <option class="form_option" value="10">Oct</option>
      <option class="form_option" value="11">Nov</option>
      <option class="form_option" value="12">Dec</option>
    </select> <select class="form_input" data-integrapay="CardExpiryYear" name="CardExpiryYear" id="card-expiry-year"> <!-- These are added by the component upon initialisation -->
      <option value="2024" selected="selected">2024</option>
      <option value="2025">2025</option>
      <option value="2026">2026</option>
      <option value="2027">2027</option>
      <option value="2028">2028</option>
      <option value="2029">2029</option>
      <option value="2030">2030</option>
      <option value="2031">2031</option>
      <option value="2032">2032</option>
    </select> </div>
  <div class="form_row"> <label class="form_label" for="CardCcv" id="CardCcvLabel">CCV/CVV:</label> <input class="form_input_with_border" data-integrapay="CardCcv" id="CardCcv" type="text" autocomplete="off"> </div> <br>
  <div class="form_row"> <label class="form_input">&nbsp;</label> <button class="form_input" data-integrapay="SubmitButton" type="button">Process Payment</button> </div>
</form>

Text Content

Disconnected from server, Reconnecting....
Dr Andy Ho
22 August 2024
Date of Procedure:
Anaesthetist
Payment To:
Dr Andy Ho
Payment Details
$565.45
$555.40

* Processing Fee:
Amount to Pay:
Charge Amount:
Credit Card Payment (AUD)
$10.05
Cardholder name:
Card number:
Expiry date: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
202420252026202720282029203020312032
CCV/CVV:

  Process Payment


* Please note credit card processing fees apply
based on a 1.75% surcharge + a 33c flat fee.
A higher surcharge of 1.10 applies to international and some pre-paid cards.