pay.usbank.com
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162.159.134.80
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Submitted URL: https://pay.usbank.com/
Effective URL: https://pay.usbank.com/Form/PaymentPortal/Start
Submission: On September 18 via automatic, source certstream-suspicious — Scanned from US
Effective URL: https://pay.usbank.com/Form/PaymentPortal/Start
Submission: On September 18 via automatic, source certstream-suspicious — Scanned from US
Form analysis 17 forms found in the DOM
<form novalidate="novalidate" id="formSearchPayment" data-componentid="formSearchPayment"
class="x-formpanel x-panel x-container x-component x-bordered home-search-form transparent x-header-position-top x-formpanel-transparent x-panel-transparent x-container-transparent x-component-transparent x-managed-borders x-paint-monitored x-layout-box-item x-layout-vbox-item"
data-xid="38">
<div
class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el x-formpanel-transparent-body-wrap-el x-panel-transparent-body-wrap-el x-container-transparent-body-wrap-el x-component-transparent-body-wrap-el"
id="ext-element-86">
<div
class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-formpanel-transparent-body-el x-panel-transparent-body-el x-container-transparent-body-el x-component-transparent-body-el x-formpanel-outer-border-trbl x-formpanel-transparent-outer-border-trbl x-panel-outer-border-trbl x-panel-transparent-outer-border-trbl x-container-outer-border-trbl x-container-transparent-outer-border-trbl x-component-outer-border-trbl x-component-transparent-outer-border-trbl"
id="ext-element-87" style="">
<div id="ValidationSummary" data-componentid="ValidationSummary" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="39">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-88"></div>
<div id="ext-element-89"></div>
</div>
<div data-componentid="formSearchPayment_container" class="x-container x-component x-widthed x-layout-auto-item" data-xid="40" id="formSearchPayment_container" style="width: 824px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-90">
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-align-left x-label-align-horizontal x-label-text-align-left x-empty x-required x-error-target-placeholder x-trigger-field im-rectangular-field NotOutlined x-selectfield-NotOutlined x-pickerfield-NotOutlined x-textfield-NotOutlined x-field-NotOutlined x-component-NotOutlined x-size-monitored x-paint-monitored x-layout-box-item x-layout-hbox-item x-flexed"
id="formSearchPayment_PayeeName" data-componentid="formSearchPayment_PayeeName" data-xid="41" style="flex: 2 2 0%;"><label class="x-label-el" id="ext-element-93" for="ext-element-91"><span class="x-label-text-el"
id="ext-element-94"></span></label>
<div class="x-body-wrap-el" id="ext-element-95">
<div class="x-body-el" id="ext-element-92">
<div class="x-input-wrap-el" id="ext-element-96">
<div class="x-before-input-el" id="ext-element-97">
<div id="ext-instaMedtrigger-1" data-componentid="ext-instaMedtrigger-1" class="x-instaMedTrigger x-trigger x-fa fa-search x-instaMedTrigger-NotOutlined x-trigger-NotOutlined" data-xid="43">
<div class="x-icon-el x-font-icon" id="ext-element-104"></div>
</div>
</div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-91" type="text" aria-readonly="false" placeholder="Enter Provider Name or Quick Pay Code" aria-required="true" autocomplete="off"
name="PayeeName" data-componentid="formSearchPayment_PayeeName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-98">
<div id="ext-expandtrigger-1" data-componentid="ext-expandtrigger-1" class="x-expandtrigger x-trigger x-interactive x-expandtrigger-NotOutlined x-trigger-NotOutlined x-hidden-display" data-xid="42">
<div class="x-icon-el x-font-icon" id="ext-element-103"></div>
</div>
</div>
</div>
<div class="x-underline-el" id="ext-element-99"></div>
</div>
<div class="x-error-el" id="ext-element-100">
<div class="x-error-icon-el x-font-icon" id="ext-element-101"></div>
<div class="x-help-message-el" id="ext-element-102"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-align-left x-label-align-horizontal x-label-text-align-left x-error-target-under x-trigger-field im-rectangular-field NotOutlined autoCompleteAddressWithIcon x-selectfield-NotOutlined x-pickerfield-NotOutlined x-textfield-NotOutlined x-field-NotOutlined x-component-NotOutlined x-paint-monitored x-size-monitored x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="formSearchPayment_AutoCompleteAddress" data-xid="44" id="formSearchPayment_AutoCompleteAddress" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-105" id="ext-element-107"><span
class="x-label-text-el"></span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-106">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-109">
<div id="ext-locationtrigger-1" data-componentid="ext-locationtrigger-1" class="x-locationTrigger x-trigger x-fa fa-map-marker x-locationTrigger-NotOutlined x-trigger-NotOutlined" data-xid="46">
<div class="x-icon-el x-font-icon" id="ext-element-108"></div>
</div>
</div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-105" aria-readonly="false" placeholder="City, State, Zip" aria-required="false" autocomplete="off"
name="AutoCompleteAddress" data-componentid="formSearchPayment_AutoCompleteAddress" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-110">
<div data-componentid="ext-expandtrigger-2" class="x-expandtrigger x-trigger x-interactive x-expandtrigger-NotOutlined x-trigger-NotOutlined x-hidden-display" data-xid="45" id="ext-expandtrigger-2">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-111"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="formSearchPayment_Submit"
class="x-component x-button x-has-icon x-widthed im-rectangular-field im-green noprint x-icon-align-left x-arrow-align-right x-button-im-green x-component-im-green x-layout-box-item x-layout-hbox-item" data-xid="47"
id="formSearchPayment_Submit" style="width: 56px;">
<div class="x-inner-el" id="ext-element-114">
<div class="x-body-el" id="ext-element-113">
<div class="x-icon-el x-font-icon x-ma ma-search" id="ext-element-116" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-115"><span class="im-screen-reader-only">Search</span></div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-112" aria-label="Search" aria-labelledby="ext-element-115"
data-componentid="formSearchPayment_Submit"></button>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
<div class="x-paint-monitor cssanimation"></div>
</form><form novalidate="novalidate" data-componentid="MoreDetailsContainer"
class="x-formpanel x-panel x-container x-component x-noborder-trbl x-hidden x-hidden-display col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="54" id="MoreDetailsContainer">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-132">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-123">
<div data-componentid="ValidationSummary_1" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="55" id="ValidationSummary_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-124"></div>
<div id="ext-element-125"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="MoreDetailsContainer_instamedHeading1" data-xid="56" id="MoreDetailsContainer_instamedHeading1">
<div class="x-body-el" id="ext-element-126">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-127" data-title="Search Results">Search Results</h1>
</div>
</div>
<div data-componentid="MoreDetailsContainer_NoResultsFound" class="x-component x-label x-hidden x-hidden-display body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="57"
id="MoreDetailsContainer_NoResultsFound">
<div class="x-innerhtml" id="ext-element-128">Your search returned zero results. Please enter the organization to pay as it appears on your bill.</div>
</div>
<div data-componentid="MoreDetailsContainer_container" class="x-container x-component x-layout-auto-item" data-xid="58" id="MoreDetailsContainer_container">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-129">
<div id="MoreDetailsContainer_ProviderBadges" data-componentid="MoreDetailsContainer_ProviderBadges" class="x-dataview x-container x-component x-hidden x-hidden-display im-providers-dataview-search x-paint-monitored x-layout-auto-item"
data-xid="59" tabindex="0">
<div class="x-body-el x-dataview-body-el x-container-body-el x-component-body-el x-show-selection x-scroller x-layout-auto" id="ext-element-130" style="overflow: hidden auto;">
<div data-componentid="ext-component-2" class="x-component x-listpaging x-hidden x-hidden-display x-scrolldock x-scrolldock-end x-layout-auto-item x-disabled" data-xid="60" id="ext-component-2" tabindex="-1">
<div class="x-innerhtml" id="ext-element-131">
<div class="x-loading-spinner"><span class="x-loading-top"></span><span class="x-loading-right"></span><span class="x-loading-bottom"></span><span class="x-loading-left"></span></div>
<div class="x-message"></div>
</div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="FindProviderForm"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-paint-monitored x-layout-auto-item"
data-xid="128" id="FindProviderForm">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-289">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-254">
<div data-componentid="ValidationSummary_2" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="129" id="ValidationSummary_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-255"></div>
<div id="ext-element-256"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="FindProviderForm_instamedHeading1" data-xid="130" id="FindProviderForm_instamedHeading1">
<div class="x-body-el" id="ext-element-257">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-258" data-title="Pay Your Healthcare Bill">Pay Your Healthcare Bill</h1>
</div>
</div>
<div data-componentid="FindProviderForm_container" class="x-container x-component MultipleFieldsContainer x-layout-auto-item" data-xid="131" id="FindProviderForm_container">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-259">
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-empty x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-trigger-field x-size-monitored x-paint-monitored x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="FindProviderForm_PayeeName" data-xid="132" id="FindProviderForm_PayeeName" style="flex: 6 6 0%;"><label class="x-label-el" for="ext-element-260" id="ext-element-262"><span class="x-label-text-el"
id="ext-element-265">Provider Name or Quick Pay Code</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-261">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-263"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-260" aria-readonly="false" aria-labelledby="ext-element-265"
placeholder="Example: ABC Clinic" aria-required="true" autocomplete="off" name="PayeeName" data-componentid="FindProviderForm_PayeeName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-264">
<div data-componentid="ext-expandtrigger-3" class="x-expandtrigger x-trigger x-interactive x-hidden-display" data-xid="133" id="ext-expandtrigger-3">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-266"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="FindProviderForm_container_1" class="x-container x-component x-widthed x-spacer x-layout-box-item x-layout-hbox-item" data-xid="134" id="FindProviderForm_container_1" style="width: 24px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-267"></div>
</div>
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-empty x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-trigger-field autoCompleteAddressWithIcon x-paint-monitored x-size-monitored x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="FindProviderForm_AutoCompleteAddress" data-xid="135" id="FindProviderForm_AutoCompleteAddress" style="flex: 4 4 0%;"><label class="x-label-el" for="ext-element-268" id="ext-element-270"><span class="x-label-text-el"
id="ext-element-273">Service Location</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-269">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-271">
<div data-componentid="ext-locationtrigger-2" class="x-locationTrigger x-trigger x-fa fa-map-marker" data-xid="137" id="ext-locationtrigger-2">
<div class="x-icon-el x-font-icon"></div>
</div>
</div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-268" aria-readonly="false" aria-labelledby="ext-element-273" aria-required="false" autocomplete="off"
name="AutoCompleteAddress" data-componentid="FindProviderForm_AutoCompleteAddress" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-272">
<div data-componentid="ext-expandtrigger-4" class="x-expandtrigger x-trigger x-interactive x-hidden-display" data-xid="136" id="ext-expandtrigger-4">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-274"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
</div>
</div>
</div>
<div data-componentid="FindProviderForm_container_2" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="138" id="FindProviderForm_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-275">
<div data-componentid="FindProviderForm_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="139" id="FindProviderForm_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="FindProviderForm_button_Back"
class="x-component x-button x-has-text secondary noprint x-icon-align-left x-arrow-align-right x-button-secondary x-component-secondary x-layout-box-item x-layout-hbox-item" data-xid="140" id="FindProviderForm_button_Back">
<div class="x-inner-el" id="ext-element-278">
<div class="x-body-el" id="ext-element-277">
<div class="x-icon-el x-font-icon" id="ext-element-280"></div>
<div class="x-text-el" id="ext-element-279">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-276" aria-labelledby="ext-element-279"
data-componentid="FindProviderForm_button_Back"></button>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="FindProviderForm_button_Search"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="141" id="FindProviderForm_button_Search">
<div class="x-inner-el" id="ext-element-283">
<div class="x-body-el" id="ext-element-282">
<div class="x-icon-el x-font-icon" id="ext-element-285"></div>
<div class="x-text-el" id="ext-element-284">Search</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-281" aria-labelledby="ext-element-284"
data-componentid="FindProviderForm_button_Search"></button>
</div>
</div>
</div>
<div data-componentid="FindProviderForm_NoResultsFound" class="x-component x-label x-hidden x-hidden-display body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="142" id="FindProviderForm_NoResultsFound">
<div class="x-innerhtml" id="ext-element-286">Your search returned zero results. Please enter the organization to pay as it appears on your bill.</div>
</div>
<div data-componentid="FindProviderForm_ProviderBadges" class="x-dataview x-container x-component x-hidden x-hidden-display im-providers-dataview-search x-paint-monitored x-layout-auto-item" data-xid="143" tabindex="0"
id="FindProviderForm_ProviderBadges">
<div class="x-body-el x-dataview-body-el x-container-body-el x-component-body-el x-show-selection x-scroller x-layout-auto" id="ext-element-287" style="overflow: hidden auto;">
<div data-componentid="ext-component-4" class="x-component x-listpaging x-hidden x-hidden-display x-scrolldock x-scrolldock-end x-layout-auto-item x-disabled" data-xid="144" id="ext-component-4" tabindex="-1">
<div class="x-innerhtml" id="ext-element-288">
<div class="x-loading-spinner"><span class="x-loading-top"></span><span class="x-loading-right"></span><span class="x-loading-bottom"></span><span class="x-loading-left"></span></div>
<div class="x-message"></div>
</div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
<div class="x-paint-monitor cssanimation"></div>
</form><form novalidate="novalidate" data-componentid="formSearchPayment_1"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="210" id="formSearchPayment_1">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-595">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-408">
<div data-componentid="ValidationSummary_3" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="211" id="ValidationSummary_3">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-409"></div>
<div id="ext-element-410"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="formSearchPayment_instamedHeading1" data-xid="212" id="formSearchPayment_instamedHeading1">
<div class="x-body-el" id="ext-element-411">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-412" data-title="Make a Payment">Make a Payment</h1>
</div>
</div>
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-hidden x-hidden-display x-label-align-placeholder x-label-align-vertical x-error-target-under x-trigger-field x-size-monitored x-paint-monitored x-layout-auto-item"
data-componentid="formSearchPayment_Patient" data-xid="213" id="formSearchPayment_Patient"><label class="x-label-el" for="ext-element-413" id="ext-element-415"><span class="x-label-text-el" id="ext-element-418">Patient</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-414">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-416"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-413" aria-readonly="false" aria-labelledby="ext-element-418"
placeholder="Select One" aria-required="false" autocomplete="off" name="Patient" data-componentid="formSearchPayment_Patient" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-417">
<div data-componentid="ext-expandtrigger-5" class="x-expandtrigger x-trigger x-interactive" data-xid="214" id="ext-expandtrigger-5">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-419"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="formSearchPayment_PatientMatchFieldsContainer" class="x-container x-component x-layout-auto-item" data-xid="215" id="formSearchPayment_PatientMatchFieldsContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-420">
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
id="formSearchPayment_EmailAddress" data-componentid="formSearchPayment_EmailAddress" data-xid="216"><label class="x-label-el" id="ext-element-423" for="ext-element-421"><span class="x-label-text-el"
id="ext-element-424">Email</span></label>
<div class="x-body-wrap-el" id="ext-element-425">
<div class="x-body-el" id="ext-element-422">
<div class="x-input-wrap-el" id="ext-element-426">
<div class="x-before-input-el" id="ext-element-427"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-421" type="email" maxlength="200" autocorrect="off"
aria-labelledby="ext-element-424" aria-required="true" autocomplete="on" name="EmailAddress" aria-readonly="false" data-componentid="formSearchPayment_EmailAddress" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-428"></div>
</div>
<div class="x-underline-el" id="ext-element-429"></div>
</div>
<div class="x-error-el" id="ext-element-430">
<div class="x-error-icon-el x-font-icon" id="ext-element-431"></div>
<div class="x-help-message-el" id="ext-element-432"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_QuickPayComboID" data-xid="217" id="formSearchPayment_QuickPayComboID"><label class="x-label-el" for="ext-element-433" id="ext-element-435"><span class="x-label-text-el"
id="ext-element-436"></span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-434">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-437"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-433" maxlength="80" autocorrect="off" name="QuickPayComboID"
aria-label="QuickPayComboID" aria-required="false" autocomplete="on" aria-readonly="false" data-componentid="formSearchPayment_QuickPayComboID" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-438"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-439"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_PatientMedicalRecordNumber" data-xid="218" id="formSearchPayment_PatientMedicalRecordNumber"><label class="x-label-el" for="ext-element-440" id="ext-element-442"><span class="x-label-text-el"
id="ext-element-443">Medical Record #</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-441">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-444"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-440" maxlength="80" autocorrect="off"
aria-labelledby="ext-element-443" aria-required="false" autocomplete="on" name="PatientMedicalRecordNumber" aria-readonly="false" data-componentid="formSearchPayment_PatientMedicalRecordNumber" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-445"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-446"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_GuarantorID" data-xid="219" id="formSearchPayment_GuarantorID"><label class="x-label-el" for="ext-element-447" id="ext-element-449"><span class="x-label-text-el" id="ext-element-450">Guarantor
ID</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-448">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-451"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-447" maxlength="80" autocorrect="off"
aria-labelledby="ext-element-450" aria-required="false" autocomplete="on" name="GuarantorID" aria-readonly="false" data-componentid="formSearchPayment_GuarantorID" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-452"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-453"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_GuarantorFirstName" data-xid="220" id="formSearchPayment_GuarantorFirstName"><label class="x-label-el" for="ext-element-454" id="ext-element-456"><span class="x-label-text-el"
id="ext-element-457">Guarantor First Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-455">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-458"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-454" maxlength="35" autocorrect="off"
aria-labelledby="ext-element-457" aria-required="false" autocomplete="on" name="GuarantorFirstName" aria-readonly="false" data-componentid="formSearchPayment_GuarantorFirstName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-459"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-460"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_GuarantorLastName" data-xid="221" id="formSearchPayment_GuarantorLastName"><label class="x-label-el" for="ext-element-461" id="ext-element-463"><span class="x-label-text-el"
id="ext-element-464">Guarantor Last Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-462">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-465"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-461" maxlength="60" autocorrect="off"
aria-labelledby="ext-element-464" aria-required="false" autocomplete="on" name="GuarantorLastName" aria-readonly="false" data-componentid="formSearchPayment_GuarantorLastName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-466"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-467"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_PatientFirstName" data-xid="222" id="formSearchPayment_PatientFirstName"><label class="x-label-el" for="ext-element-468" id="ext-element-470"><span class="x-label-text-el" id="ext-element-471">Patient
First Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-469">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-472"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-468" maxlength="35" autocorrect="off"
aria-labelledby="ext-element-471" aria-required="false" autocomplete="on" name="PatientFirstName" aria-readonly="false" data-componentid="formSearchPayment_PatientFirstName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-473"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-474"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_PatientLastName" data-xid="223" id="formSearchPayment_PatientLastName"><label class="x-label-el" for="ext-element-475" id="ext-element-477"><span class="x-label-text-el" id="ext-element-478">Patient
Last Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-476">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-479"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-475" maxlength="60" autocorrect="off"
aria-labelledby="ext-element-478" aria-required="false" autocomplete="on" name="PatientLastName" aria-readonly="false" data-componentid="formSearchPayment_PatientLastName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-480"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-481"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_PatientMiddleName" data-xid="224" id="formSearchPayment_PatientMiddleName"><label class="x-label-el" for="ext-element-482" id="ext-element-484"><span class="x-label-text-el"
id="ext-element-485">Middle</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-483">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-486"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-482" maxlength="25" autocorrect="off"
aria-labelledby="ext-element-485" aria-required="false" autocomplete="on" name="PatientMiddleName" aria-readonly="false" data-componentid="formSearchPayment_PatientMiddleName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-487"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-488"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-datepickerfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-size-monitored x-paint-monitored x-layout-auto-item"
id="formSearchPayment_PatientBirthDate" data-componentid="formSearchPayment_PatientBirthDate" data-xid="225"><label class="x-label-el" id="ext-element-491" for="ext-element-489"><span class="x-label-text-el" id="ext-element-492">Patient's
Date of Birth</span></label>
<div class="x-body-wrap-el" id="ext-element-493">
<div class="x-body-el" id="ext-element-490">
<div class="x-input-wrap-el" id="ext-element-494">
<div class="x-before-input-el" id="ext-element-495"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-489" type="text" aria-labelledby="ext-element-492" placeholder="MM/DD/YYYY"
aria-required="false" autocomplete="on" name="PatientBirthDate" aria-readonly="false" data-componentid="formSearchPayment_PatientBirthDate" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-496">
<div id="ext-datetrigger-1" data-componentid="ext-datetrigger-1" class="x-datetrigger x-trigger x-interactive" data-xid="226">
<div class="x-icon-el x-font-icon" id="ext-element-501"></div>
</div>
</div>
</div>
<div class="x-underline-el" id="ext-element-497"></div>
</div>
<div class="x-error-el" id="ext-element-498">
<div class="x-error-icon-el x-font-icon" id="ext-element-499"></div>
<div class="x-help-message-el" id="ext-element-500"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_PatientPhoneNumber" data-xid="227" id="formSearchPayment_PatientPhoneNumber"><label class="x-label-el" for="ext-element-502" id="ext-element-504"><span class="x-label-text-el" id="ext-element-505">Phone
Number</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-503">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-506"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="tel" id="ext-element-502" maxlength="14" autocorrect="off"
aria-labelledby="ext-element-505" aria-required="false" autocomplete="on" name="PatientPhoneNumber" aria-readonly="false" data-componentid="formSearchPayment_PatientPhoneNumber" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-507"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-508"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_PatientZip" data-xid="228" id="formSearchPayment_PatientZip"><label class="x-label-el" for="ext-element-509" id="ext-element-511"><span class="x-label-text-el" id="ext-element-512">Zip</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-510">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-513"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-509" maxlength="10" autocorrect="off"
aria-labelledby="ext-element-512" aria-required="false" autocomplete="on" name="PatientZip" aria-readonly="false" data-componentid="formSearchPayment_PatientZip" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-514"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-515"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_StatementNumber" data-xid="229" id="formSearchPayment_StatementNumber"><label class="x-label-el" for="ext-element-516" id="ext-element-518"><span class="x-label-text-el" id="ext-element-519">Statement
Number</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-517">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-520"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-516" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-519" aria-required="false" autocomplete="off" name="StatementNumber" aria-readonly="false" data-componentid="formSearchPayment_StatementNumber" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-521"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-522"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-datepickerfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-size-monitored x-paint-monitored x-layout-auto-item"
data-componentid="formSearchPayment_StatementDate" data-xid="230" id="formSearchPayment_StatementDate"><label class="x-label-el" for="ext-element-523" id="ext-element-525"><span class="x-label-text-el" id="ext-element-526">Statement
Date</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-524">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-527"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-523" aria-labelledby="ext-element-526" placeholder="MM/DD/YYYY"
aria-required="false" autocomplete="off" name="StatementDate" aria-readonly="false" data-componentid="formSearchPayment_StatementDate" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-528">
<div data-componentid="ext-datetrigger-2" class="x-datetrigger x-trigger x-interactive" data-xid="231" id="ext-datetrigger-2">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-529"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
id="formSearchPayment_AmountDue" data-componentid="formSearchPayment_AmountDue" data-xid="232"><label class="x-label-el" id="ext-element-532" for="ext-element-530"><span class="x-label-text-el" id="ext-element-533">Amount
Due</span></label>
<div class="x-body-wrap-el" id="ext-element-534">
<div class="x-body-el" id="ext-element-531">
<div class="x-input-wrap-el" id="ext-element-535">
<div class="x-before-input-el" id="ext-element-536"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-530" type="text" maxlength="12" autocorrect="off"
aria-labelledby="ext-element-533" aria-required="false" autocomplete="off" name="AmountDue" aria-readonly="false" data-componentid="formSearchPayment_AmountDue" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-537"></div>
</div>
<div class="x-underline-el" id="ext-element-538"></div>
</div>
<div class="x-error-el" id="ext-element-539">
<div class="x-error-icon-el x-font-icon" id="ext-element-540"></div>
<div class="x-help-message-el" id="ext-element-541"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_DynamicField1" data-xid="233" id="formSearchPayment_DynamicField1"><label class="x-label-el" for="ext-element-542" id="ext-element-544"><span class="x-label-text-el" id="ext-element-545">Dynamic Field
1</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-543">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-546"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-542" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-545" aria-required="false" autocomplete="off" name="DynamicField1" aria-readonly="false" data-componentid="formSearchPayment_DynamicField1" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-547"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-548"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_DynamicField2" data-xid="234" id="formSearchPayment_DynamicField2"><label class="x-label-el" for="ext-element-549" id="ext-element-551"><span class="x-label-text-el" id="ext-element-552">Dynamic Field
2</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-550">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-553"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-549" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-552" aria-required="false" autocomplete="off" name="DynamicField2" aria-readonly="false" data-componentid="formSearchPayment_DynamicField2" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-554"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-555"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_DynamicField3" data-xid="235" id="formSearchPayment_DynamicField3"><label class="x-label-el" for="ext-element-556" id="ext-element-558"><span class="x-label-text-el" id="ext-element-559">Dynamic Filed
3</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-557">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-560"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-556" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-559" aria-required="false" autocomplete="off" name="DynamicField3" aria-readonly="false" data-componentid="formSearchPayment_DynamicField3" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-561"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-562"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-hidden x-hidden-display x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="formSearchPayment_DynamicField4" data-xid="236" id="formSearchPayment_DynamicField4"><label class="x-label-el" for="ext-element-563" id="ext-element-565"><span class="x-label-text-el" id="ext-element-566">Dynamic Field
4</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-564">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-567"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-563" maxlength="80" autocorrect="off"
aria-labelledby="ext-element-566" aria-required="false" autocomplete="off" name="DynamicField4" aria-readonly="false" data-componentid="formSearchPayment_DynamicField4" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-568"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-569"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item" id="formSearchPayment_ProviderAlias"
data-componentid="formSearchPayment_ProviderAlias" data-xid="237"><label class="x-label-el" id="ext-element-572" for="ext-element-570"><span class="x-label-text-el" id="ext-element-573">ProviderAlias</span></label>
<div class="x-body-wrap-el" id="ext-element-574">
<div class="x-body-el" id="ext-element-571"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-570" type="hidden" aria-labelledby="ext-element-573" aria-required="false" name="ProviderAlias"
aria-readonly="false" data-componentid="formSearchPayment_ProviderAlias" aria-invalid="false"></div>
<div class="x-error-el" id="ext-element-575">
<div class="x-error-icon-el x-font-icon" id="ext-element-576"></div>
<div class="x-help-message-el" id="ext-element-577"></div>
</div>
</div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="formSearchPayment_QuickPayFlowFromPaymentPage" data-xid="238" id="formSearchPayment_QuickPayFlowFromPaymentPage"><label class="x-label-el" for="ext-element-578" id="ext-element-580"><span class="x-label-text-el"
id="ext-element-581">QuickPayFlowFromPaymentPage</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-579"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-578" aria-labelledby="ext-element-581" aria-required="false"
name="QuickPayFlowFromPaymentPage" aria-readonly="false" data-componentid="formSearchPayment_QuickPayFlowFromPaymentPage" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-582"></div>
</div>
</div>
</div>
<div data-componentid="formSearchPayment_container_1" class="x-container x-component x-layout-auto-item" data-xid="239" id="formSearchPayment_container_1" style="margin: 16px 0px !important;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-583">
<div onclick="return Ext.doEv(this, event);" data-componentid="formSearchPayment_button_PayNow"
class="x-component x-button x-has-text x-button-action wide noprint x-icon-align-left x-arrow-align-right x-button-wide x-component-wide x-layout-auto-item" data-xid="240" id="formSearchPayment_button_PayNow">
<div class="x-inner-el" id="ext-element-586">
<div class="x-body-el" id="ext-element-585">
<div class="x-icon-el x-font-icon" id="ext-element-588"></div>
<div class="x-text-el" id="ext-element-587">Pay Now</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-584" aria-labelledby="ext-element-587"
data-componentid="formSearchPayment_button_PayNow"></button>
</div>
</div>
</div>
<div data-componentid="formSearchPayment_container_2" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="241" id="formSearchPayment_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-589">
<div data-componentid="formSearchPayment_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="242" id="formSearchPayment_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="formSearchPayment_button_Next"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="243" id="formSearchPayment_button_Next">
<div class="x-inner-el" id="ext-element-592">
<div class="x-body-el" id="ext-element-591">
<div class="x-icon-el x-font-icon" id="ext-element-594"></div>
<div class="x-text-el" id="ext-element-593">Next</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-590" aria-labelledby="ext-element-593"
data-componentid="formSearchPayment_button_Next"></button>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="FormQuickPaySignUp"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="309" id="FormQuickPaySignUp">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-805">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-714">
<div data-componentid="ValidationSummary_4" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="310" id="ValidationSummary_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-715"></div>
<div id="ext-element-716"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="FormQuickPaySignUp_instamedHeading1" data-xid="311" id="FormQuickPaySignUp_instamedHeading1">
<div class="x-body-el" id="ext-element-717">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-718" data-title="Sign Up for an Account Today!">Sign Up for an Account Today!</h1>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_container" class="x-container x-component im-top-label im-bottom-label x-layout-auto-item" data-xid="312" id="FormQuickPaySignUp_container">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-719">
<div data-componentid="FormQuickPaySignUp_label" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="313" id="FormQuickPaySignUp_label">
<div class="x-innerhtml" id="ext-element-720">Save this payment to your account and make future payments even easier! Already have an Account? <span tabindex="0" onclick="NavigateToLoginPage()"
onkeydown="InstaMed.keyboardHandler(event,NavigateToLoginPage)" class="x-label-body1-link-blue"> Log In</span></div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_QuickPaySignUpAccountContainer" class="x-container x-component x-hidden x-hidden-display im-dataview-tile im-dataview-tile-noborder x-paint-monitored x-layout-auto-item" data-xid="314"
id="FormQuickPaySignUp_QuickPaySignUpAccountContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-721">
<div data-componentid="FormQuickPaySignUp_PatientNameInitials" class="x-component x-label im-dataview-logo x-layout-box-item x-layout-hbox-item" data-xid="315" id="FormQuickPaySignUp_PatientNameInitials">
<div class="x-innerhtml" id="ext-element-722"></div>
</div>
<div data-componentid="FormQuickPaySignUp_container_1" class="x-container x-component im-dataview-text-container im-quickpay-user-tile x-layout-box-item x-layout-hbox-item x-flexed" data-xid="316" id="FormQuickPaySignUp_container_1"
style="flex: 1 1 0%;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-723">
<div data-componentid="FormQuickPaySignUp_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="317" id="FormQuickPaySignUp_container_2" style="flex: 1 1 0%;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-724">
<div data-componentid="FormQuickPaySignUp_PatientName" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="318" id="FormQuickPaySignUp_PatientName">
<div class="x-innerhtml" id="ext-element-725"></div>
</div>
<div data-componentid="FormQuickPaySignUp_PatientEmail" class="x-component x-label body1-secondary x-label-body1-secondary x-component-body1-secondary x-layout-auto-item" data-xid="319" id="FormQuickPaySignUp_PatientEmail"></div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_container_3" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="320" id="FormQuickPaySignUp_container_3">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-726">
<div class="x-innerhtml" id="ext-element-727"><span tabindex="0" class="secondary-color x-ma ma-mode-edit x-icon-el x-font-icon"></span></div>
</div>
</div>
</div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="FormQuickPaySignUp_Email" data-xid="321" id="FormQuickPaySignUp_Email"><label class="x-label-el" for="ext-element-728" id="ext-element-730"><span class="x-label-text-el" id="ext-element-731">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-729">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-732"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-728" maxlength="80" autocorrect="off"
aria-labelledby="ext-element-731" aria-required="true" autocomplete="on" name="Email" aria-readonly="false" data-componentid="FormQuickPaySignUp_Email" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-733"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-734"></div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_QuickPayNameContainer" class="x-container x-component MultipleFieldsContainer x-layout-auto-item" data-xid="322" id="FormQuickPaySignUp_QuickPayNameContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-735">
<div
class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="FormQuickPaySignUp_FirstName" data-xid="323" id="FormQuickPaySignUp_FirstName" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-736" id="ext-element-738"><span class="x-label-text-el"
id="ext-element-739">First Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-737">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-740"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-736" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-739" aria-required="true" autocomplete="on" name="FirstName" aria-readonly="false" data-componentid="FormQuickPaySignUp_FirstName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-741"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-742"></div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_FirstNameLastNameSpacer" class="x-container x-component x-widthed x-spacer x-layout-box-item x-layout-hbox-item" data-xid="324" id="FormQuickPaySignUp_FirstNameLastNameSpacer" style="width: 24px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-743"></div>
</div>
<div
class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="FormQuickPaySignUp_LastName" data-xid="325" id="FormQuickPaySignUp_LastName" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-744" id="ext-element-746"><span class="x-label-text-el"
id="ext-element-747">Last Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-745">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-748"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-744" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-747" aria-required="true" autocomplete="on" name="LastName" aria-readonly="false" data-componentid="FormQuickPaySignUp_LastName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-749"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-750"></div>
</div>
</div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
id="FormQuickPaySignUp_Password" data-componentid="FormQuickPaySignUp_Password" data-xid="326"><label class="x-label-el" id="ext-element-753" for="ext-element-751"><span class="x-label-text-el" id="ext-element-754">Password</span></label>
<div class="x-body-wrap-el" id="ext-element-755">
<div class="x-body-el" id="ext-element-752">
<div class="x-input-wrap-el" id="ext-element-756">
<div class="x-before-input-el" id="ext-element-757"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-751" type="password" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-754" aria-required="true" autocomplete="on" name="Password" autocapitalize="off" aria-readonly="false" data-componentid="FormQuickPaySignUp_Password" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-758">
<div id="ext-revealtrigger-1" data-componentid="ext-revealtrigger-1" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="327">
<div class="x-icon-el x-font-icon" id="ext-element-763"></div>
</div>
</div>
</div>
<div class="x-underline-el" id="ext-element-759"></div>
</div>
<div class="x-error-el" id="ext-element-760">
<div class="x-error-icon-el x-font-icon" id="ext-element-761"></div>
<div class="x-help-message-el" id="ext-element-762"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="FormQuickPaySignUp_PasswordVisualizerChecklist" class="x-container x-component x-hidden x-hidden-display x-layout-auto-item" data-xid="328" id="FormQuickPaySignUp_PasswordVisualizerChecklist">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-764">
<div data-componentid="FormQuickPaySignUp_label_1" class="x-component x-label x-layout-auto-item" data-xid="329" id="FormQuickPaySignUp_label_1">
<div class="x-innerhtml" id="ext-element-765">Password must:</div>
</div>
<div data-componentid="FormQuickPaySignUp_container_4" class="x-container x-component x-layout-auto-item" data-xid="330" id="FormQuickPaySignUp_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-766">
<div id="FormQuickPaySignUp_8charsIcon" data-componentid="FormQuickPaySignUp_8charsIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="331">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-767"></div>
</div>
<div data-componentid="FormQuickPaySignUp_8charsLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="332" id="FormQuickPaySignUp_8charsLabel">
<div class="x-innerhtml" id="ext-element-768">Contain at least 8 characters</div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_CharacterTypes" class="x-component x-label RedLabel x-layout-auto-item" data-xid="333" id="FormQuickPaySignUp_CharacterTypes">
<div class="x-innerhtml" id="ext-element-769">Contain at least 3 of the following 4 characters:</div>
</div>
<div data-componentid="FormQuickPaySignUp_container_5" class="x-container x-component x-layout-auto-item" data-xid="334" id="FormQuickPaySignUp_container_5">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-770">
<div data-componentid="FormQuickPaySignUp_lowerCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="335" id="FormQuickPaySignUp_lowerCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-771"></div>
</div>
<div data-componentid="FormQuickPaySignUp_lowerCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="336" id="FormQuickPaySignUp_lowerCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-772">1 lowercase letter</div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_container_6" class="x-container x-component x-layout-auto-item" data-xid="337" id="FormQuickPaySignUp_container_6">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-773">
<div data-componentid="FormQuickPaySignUp_upperCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="338" id="FormQuickPaySignUp_upperCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-774"></div>
</div>
<div data-componentid="FormQuickPaySignUp_upperCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="339" id="FormQuickPaySignUp_upperCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-775">1 uppercase letter</div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_container_7" class="x-container x-component x-layout-auto-item" data-xid="340" id="FormQuickPaySignUp_container_7">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-776">
<div data-componentid="FormQuickPaySignUp_oneNumberIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="341" id="FormQuickPaySignUp_oneNumberIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-777"></div>
</div>
<div data-componentid="FormQuickPaySignUp_oneNumberLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="342" id="FormQuickPaySignUp_oneNumberLabel">
<div class="x-innerhtml" id="ext-element-778">1 number</div>
</div>
</div>
</div>
<div data-componentid="FormQuickPaySignUp_container_8" class="x-container x-component x-layout-auto-item" data-xid="343" id="FormQuickPaySignUp_container_8">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-779">
<div data-componentid="FormQuickPaySignUp_OneSymbolIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="344" id="FormQuickPaySignUp_OneSymbolIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-780"></div>
</div>
<div data-componentid="FormQuickPaySignUp_OneSymbolLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="345" id="FormQuickPaySignUp_OneSymbolLabel">
<div class="x-innerhtml" id="ext-element-781">1 special character</div>
</div>
</div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="FormQuickPaySignUp_ConfirmNewPassword" data-xid="346" id="FormQuickPaySignUp_ConfirmNewPassword"><label class="x-label-el" for="ext-element-782" id="ext-element-784"><span class="x-label-text-el" id="ext-element-785">Confirm
Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-783">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-786"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-782" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-785" aria-required="true" autocomplete="on" name="ConfirmNewPassword" autocapitalize="off" aria-readonly="false" data-componentid="FormQuickPaySignUp_ConfirmNewPassword" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-787">
<div data-componentid="ext-revealtrigger-2" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="347" id="ext-revealtrigger-2">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-788"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="FormQuickPaySignUp_container_9" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="348" id="FormQuickPaySignUp_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-789">
<div onclick="return Ext.doEv(this, event);" data-componentid="FormQuickPaySignUp_button_ContinueasGuest" class="x-component x-button x-has-text noprint x-icon-align-left x-arrow-align-right x-layout-box-item x-layout-hbox-item"
data-xid="349" id="FormQuickPaySignUp_button_ContinueasGuest">
<div class="x-inner-el" id="ext-element-792">
<div class="x-body-el" id="ext-element-791">
<div class="x-icon-el x-font-icon" id="ext-element-794"></div>
<div class="x-text-el" id="ext-element-793">Continue as Guest</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-790" aria-labelledby="ext-element-793"
data-componentid="FormQuickPaySignUp_button_ContinueasGuest"></button>
</div>
<div data-componentid="FormQuickPaySignUp_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="350" id="FormQuickPaySignUp_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="FormQuickPaySignUp_button_Back"
class="x-component x-button x-has-text secondary noprint x-icon-align-left x-arrow-align-right x-button-secondary x-component-secondary x-layout-box-item x-layout-hbox-item" data-xid="351" id="FormQuickPaySignUp_button_Back">
<div class="x-inner-el" id="ext-element-797">
<div class="x-body-el" id="ext-element-796">
<div class="x-icon-el x-font-icon" id="ext-element-799"></div>
<div class="x-text-el" id="ext-element-798">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-795" aria-labelledby="ext-element-798"
data-componentid="FormQuickPaySignUp_button_Back"></button>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="FormQuickPaySignUp_button_Next"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="352" id="FormQuickPaySignUp_button_Next">
<div class="x-inner-el" id="ext-element-802">
<div class="x-body-el" id="ext-element-801">
<div class="x-icon-el x-font-icon" id="ext-element-804"></div>
<div class="x-text-el" id="ext-element-803">Next</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-800" aria-labelledby="ext-element-803"
data-componentid="FormQuickPaySignUp_button_Next"></button>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="LoginPage"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="418" id="LoginPage">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-982">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-924">
<div data-componentid="ValidationSummary_5" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="419" id="ValidationSummary_5">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-925"></div>
<div id="ext-element-926"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="LoginPage_instamedHeading1" data-xid="420" id="LoginPage_instamedHeading1">
<div class="x-body-el" id="ext-element-927">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-928" data-title="Please Log In to Continue">Please Log In to Continue</h1>
</div>
</div>
<div data-componentid="LoginPage_QuickPayLoginAccountContainer" class="x-container x-component x-hidden x-hidden-display im-dataview-tile im-dataview-tile-noborder x-layout-auto-item" data-xid="421" id="LoginPage_QuickPayLoginAccountContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-929">
<div data-componentid="LoginPage_PatientNameInitials" class="x-component x-label im-dataview-logo x-layout-box-item x-layout-hbox-item" data-xid="422" id="LoginPage_PatientNameInitials">
<div class="x-innerhtml" id="ext-element-930"></div>
</div>
<div data-componentid="LoginPage_container" class="x-container x-component im-dataview-text-container im-quickpay-user-tile x-layout-box-item x-layout-hbox-item x-flexed" data-xid="423" id="LoginPage_container" style="flex: 1 1 0%;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-931">
<div data-componentid="LoginPage_container_1" class="x-container x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="424" id="LoginPage_container_1" style="flex: 1 1 0%;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-932">
<div data-componentid="LoginPage_PatientName" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="425" id="LoginPage_PatientName">
<div class="x-innerhtml" id="ext-element-933"></div>
</div>
<div data-componentid="LoginPage_PatientEmail" class="x-component x-label body1-secondary x-label-body1-secondary x-component-body1-secondary x-layout-auto-item" data-xid="426" id="LoginPage_PatientEmail"></div>
</div>
</div>
<div data-componentid="LoginPage_SignupLinkContainerTileComponent" class="x-container x-component im-right-text-wrapper x-layout-box-item x-layout-hbox-item" data-xid="427" id="LoginPage_SignupLinkContainerTileComponent">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-934">
<div data-componentid="LoginPage_label" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="428" id="LoginPage_label">
<div class="x-innerhtml" id="ext-element-935"><span tabindex="0" onclick="NavigateToSignUpPage();return false;" onkeydown="InstaMed.keyboardHandler(event,NavigateToSignUpPage)" class="x-label-body1-link-blue">Sign Up</span></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div data-componentid="LoginPage_UseDifferentAccountComponent" class="x-container x-component im-top-label im-bottom-label x-layout-auto-item" data-xid="429" id="LoginPage_UseDifferentAccountComponent">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-936">
<div data-componentid="LoginPage_label_1" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="430" id="LoginPage_label_1">
<div class="x-innerhtml" id="ext-element-937"><span tabindex="0" onclick="revealEmailField()" onkeydown="InstaMed.keyboardHandler(event,revealEmailField)" class="x-label-body1-link-blue">Use different account</span></div>
</div>
</div>
</div>
<div data-componentid="LoginPage_SignupLinkContainer" class="x-container x-component im-right-text-wrapper x-layout-auto-item" data-xid="431" id="LoginPage_SignupLinkContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-938">
<div data-componentid="LoginPage_label_2" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="432" id="LoginPage_label_2">
<div class="x-innerhtml" id="ext-element-939"><span tabindex="0" onclick="NavigateToSignUpPage();return false;" onkeydown="InstaMed.keyboardHandler(event,NavigateToSignUpPage)" class="x-label-body1-link-blue">Sign Up</span></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="LoginPage_Email" data-xid="433" id="LoginPage_Email"><label class="x-label-el" for="ext-element-940" id="ext-element-942"><span class="x-label-text-el" id="ext-element-943">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-941">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-944"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-940" maxlength="200" autocorrect="off"
aria-labelledby="ext-element-943" aria-required="false" autocomplete="on" name="Email" aria-readonly="false" data-componentid="LoginPage_Email" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-945"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-946"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="LoginPage_Password" data-xid="434" id="LoginPage_Password"><label class="x-label-el" for="ext-element-947" id="ext-element-949"><span class="x-label-text-el" id="ext-element-950">Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-948">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-951"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-947" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-950" aria-required="true" autocomplete="on" name="Password" autocapitalize="off" aria-readonly="false" data-componentid="LoginPage_Password" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-952">
<div data-componentid="ext-revealtrigger-3" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="435" id="ext-revealtrigger-3">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-953"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="LoginPage_ForgotPassowrdLinkComponent" class="x-container x-component im-top-label im-bottom-label x-layout-auto-item" data-xid="436" id="LoginPage_ForgotPassowrdLinkComponent">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-954">
<div data-componentid="LoginPage_label_3" class="x-component x-label body1-primary x-label-body1-primary x-component-body1-primary x-layout-auto-item" data-xid="437" id="LoginPage_label_3">
<div class="x-innerhtml" id="ext-element-955"><span tabindex="0" onclick="quickPayForgotPassword()" onkeydown="InstaMed.keyboardHandler(event,quickPayForgotPassword)" class="x-label-body1-link-blue">Forgot Password?</span></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="LoginPage_UserIsEnterCustomEmail" data-xid="438" id="LoginPage_UserIsEnterCustomEmail"><label class="x-label-el" for="ext-element-956" id="ext-element-958"><span class="x-label-text-el"
id="ext-element-959">UserIsEnterCustomEmail</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-957"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-956" aria-labelledby="ext-element-959" value="false" aria-required="false"
name="UserIsEnterCustomEmail" aria-readonly="false" data-componentid="LoginPage_UserIsEnterCustomEmail" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-960"></div>
</div>
</div>
</div>
<div data-componentid="LoginPage_container_2" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="439" id="LoginPage_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-961">
<div onclick="return Ext.doEv(this, event);" data-componentid="LoginPage_button_ForgotPassword"
class="x-component x-button x-has-text x-hidden x-hidden-display noprint x-icon-align-left x-arrow-align-right x-layout-box-item x-layout-hbox-item" data-xid="440" id="LoginPage_button_ForgotPassword">
<div class="x-inner-el" id="ext-element-964">
<div class="x-body-el" id="ext-element-963">
<div class="x-icon-el x-font-icon" id="ext-element-966"></div>
<div class="x-text-el" id="ext-element-965">Forgot Password?</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-962" aria-labelledby="ext-element-965"
data-componentid="LoginPage_button_ForgotPassword"></button>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="LoginPage_button_ContinueasGuest" class="x-component x-button x-has-text noprint x-icon-align-left x-arrow-align-right x-layout-box-item x-layout-hbox-item" data-xid="441"
id="LoginPage_button_ContinueasGuest">
<div class="x-inner-el" id="ext-element-969">
<div class="x-body-el" id="ext-element-968">
<div class="x-icon-el x-font-icon" id="ext-element-971"></div>
<div class="x-text-el" id="ext-element-970">Continue as Guest</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-967" aria-labelledby="ext-element-970"
data-componentid="LoginPage_button_ContinueasGuest"></button>
</div>
<div data-componentid="LoginPage_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="442" id="LoginPage_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="LoginPage_button_Back"
class="x-component x-button x-has-text secondary noprint x-icon-align-left x-arrow-align-right x-button-secondary x-component-secondary x-layout-box-item x-layout-hbox-item" data-xid="443" id="LoginPage_button_Back">
<div class="x-inner-el" id="ext-element-974">
<div class="x-body-el" id="ext-element-973">
<div class="x-icon-el x-font-icon" id="ext-element-976"></div>
<div class="x-text-el" id="ext-element-975">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-972" aria-labelledby="ext-element-975"
data-componentid="LoginPage_button_Back"></button>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="LoginPage_button_Next"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="444" id="LoginPage_button_Next">
<div class="x-inner-el" id="ext-element-979">
<div class="x-body-el" id="ext-element-978">
<div class="x-icon-el x-font-icon" id="ext-element-981"></div>
<div class="x-text-el" id="ext-element-980">Next</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-977" aria-labelledby="ext-element-980"
data-componentid="LoginPage_button_Next"></button>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="RequestPasswordReset"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="510" id="RequestPasswordReset">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-1135">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-1101">
<div data-componentid="ValidationSummary_6" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="511" id="ValidationSummary_6">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-1102"></div>
<div id="ext-element-1103"></div>
</div>
<div data-componentid="RequestPasswordReset_container" class="x-container x-component x-layout-auto-item" data-xid="512" id="RequestPasswordReset_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1104"></div>
</div>
<div data-componentid="RequestPasswordReset_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="513" id="RequestPasswordReset_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1105">
<div data-componentid="RequestPasswordReset_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="514" id="RequestPasswordReset_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="RequestPasswordReset_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="515" id="RequestPasswordReset_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1106">
<div class="x-innerhtml" id="ext-element-1107"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="516" id="RequestPasswordReset_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_3" class="x-container x-component x-layout-auto-item" data-xid="517" id="RequestPasswordReset_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1108"></div>
</div>
<div data-componentid="RequestPasswordReset_container_4" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="518" id="RequestPasswordReset_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1109">
<div data-componentid="RequestPasswordReset_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="519" id="RequestPasswordReset_spacer_2" style="flex: 1 1 0%;"></div>
<div id="RequestPasswordReset_instamedLabelHeading1" data-componentid="RequestPasswordReset_instamedLabelHeading1"
class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="520">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-1110">Forgot Password</h1>
</div>
<div data-componentid="RequestPasswordReset_spacer_3" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="521" id="RequestPasswordReset_spacer_3" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_5" class="x-container x-component x-layout-auto-item" data-xid="522" id="RequestPasswordReset_container_5" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1111"></div>
</div>
<div data-componentid="RequestPasswordReset_container_6" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="523" id="RequestPasswordReset_container_6">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1112">
<div data-componentid="RequestPasswordReset_spacer_4" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="524" id="RequestPasswordReset_spacer_4" style="flex: 1 1 0%;"></div>
<div data-componentid="RequestPasswordReset_ForgotPasswordEnterEmail"
class="x-component x-label im-font-500 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item" data-xid="525"
id="RequestPasswordReset_ForgotPasswordEnterEmail">
<div class="x-innerhtml" id="ext-element-1113">Please enter the email address associated with your account. If you do not remember the email used, please contact <a href="tel:8664678263">(866) 467-8263</a>.</div>
</div>
<div data-componentid="RequestPasswordReset_spacer_5" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="526" id="RequestPasswordReset_spacer_5" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_7" class="x-container x-component x-layout-auto-item" data-xid="527" id="RequestPasswordReset_container_7" style="min-height: 20px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1114"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="RequestPasswordReset_Email" data-xid="528" id="RequestPasswordReset_Email"><label class="x-label-el" for="ext-element-1115" id="ext-element-1117"><span class="x-label-text-el" id="ext-element-1118">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1116">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1119"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-1115" maxlength="200" autocorrect="off"
aria-labelledby="ext-element-1118" aria-required="true" autocomplete="on" name="Email" aria-readonly="false" data-componentid="RequestPasswordReset_Email" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1120"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1121"></div>
</div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_8" class="x-container x-component x-layout-auto-item" data-xid="529" id="RequestPasswordReset_container_8" style="min-height: 12px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1122"></div>
</div>
<div data-componentid="RequestPasswordReset_container_9" class="x-container x-component x-layout-auto-item" data-xid="530" id="RequestPasswordReset_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-1123">
<div onclick="return Ext.doEv(this, event);" data-componentid="RequestPasswordReset_button_Next"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="531"
id="RequestPasswordReset_button_Next">
<div class="x-inner-el" id="ext-element-1126">
<div class="x-body-el" id="ext-element-1125">
<div class="x-icon-el x-font-icon" id="ext-element-1128"></div>
<div class="x-text-el" id="ext-element-1127">Next</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1124" aria-labelledby="ext-element-1127"
data-componentid="RequestPasswordReset_button_Next"></button>
</div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_10" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="532" id="RequestPasswordReset_container_10">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-1129">
<div onclick="return Ext.doEv(this, event);" data-componentid="RequestPasswordReset_button_Back"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="533"
id="RequestPasswordReset_button_Back">
<div class="x-inner-el" id="ext-element-1132">
<div class="x-body-el" id="ext-element-1131">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-1134" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-1133">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1130" aria-labelledby="ext-element-1133"
data-componentid="RequestPasswordReset_button_Back"></button>
</div>
<div data-componentid="RequestPasswordReset_spacer_6" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="534" id="RequestPasswordReset_spacer_6" style="flex: 1 1 0%;"></div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="SignUpPage" class="x-formpanel x-panel x-container x-component x-noborder-trbl im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item" data-xid="601" id="SignUpPage">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-1345">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-scroller x-noborder-trbl" style="border-width: 0px; overflow: auto;" id="ext-element-1255">
<div data-componentid="ValidationSummary_7" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="602" id="ValidationSummary_7">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-1256"></div>
<div id="ext-element-1257"></div>
</div>
<div data-componentid="SignUpPage_container" class="x-container x-component x-layout-auto-item" data-xid="603" id="SignUpPage_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1258"></div>
</div>
<div data-componentid="SignUpPage_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="604" id="SignUpPage_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1259">
<div data-componentid="SignUpPage_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="605" id="SignUpPage_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="SignUpPage_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="606" id="SignUpPage_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1260">
<div class="x-innerhtml" id="ext-element-1261"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="SignUpPage_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="607" id="SignUpPage_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="SignUpPage_container_3" class="x-container x-component x-layout-auto-item" data-xid="608" id="SignUpPage_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1262"></div>
</div>
<div data-componentid="SignUpPage_container_4" class="x-container x-component x-layout-auto-item" data-xid="609" id="SignUpPage_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1263">
<div data-componentid="SignUpPage_container_5" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="610" id="SignUpPage_container_5">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1264">
<div data-componentid="SignUpPage_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="611" id="SignUpPage_spacer_2" style="flex: 1 1 0%;"></div>
<div data-componentid="SignUpPage_instamedLabelHeading1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="612"
id="SignUpPage_instamedLabelHeading1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-1265">Sign up</h1>
</div>
<div data-componentid="SignUpPage_spacer_3" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="613" id="SignUpPage_spacer_3" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="SignUpPage_container_6" class="x-container x-component x-layout-auto-item" data-xid="614" id="SignUpPage_container_6" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1266"></div>
</div>
<div data-componentid="SignUpPage_container_7" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="615" id="SignUpPage_container_7">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1267">
<div data-componentid="SignUpPage_spacer_4" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="616" id="SignUpPage_spacer_4" style="flex: 1 1 0%;"></div>
<div data-componentid="SignUpPage_label" class="x-component x-label im-font-500 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item" data-xid="617"
id="SignUpPage_label">
<div class="x-innerhtml" id="ext-element-1268">Create an account to continue.</div>
</div>
<div data-componentid="SignUpPage_spacer_5" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="618" id="SignUpPage_spacer_5" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="SignUpPage_container_8" class="x-container x-component x-layout-auto-item" data-xid="619" id="SignUpPage_container_8" style="min-height: 20px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1269"></div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_container_9" class="x-container x-component MultipleFieldsContainer x-layout-auto-item" data-xid="620" id="SignUpPage_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-1270">
<div
class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-empty x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="SignUpPage_FirstName" data-xid="621" id="SignUpPage_FirstName" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-1271" id="ext-element-1273"><span class="x-label-text-el" id="ext-element-1274">First
Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1272">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1275"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1271" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-1274" aria-required="true" autocomplete="on" name="FirstName" aria-readonly="false" data-componentid="SignUpPage_FirstName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1276"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1277"></div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_FirstNameLastNameSpacer" class="x-container x-component x-widthed x-spacer x-layout-box-item x-layout-hbox-item" data-xid="622" id="SignUpPage_FirstNameLastNameSpacer" style="width: 24px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1278"></div>
</div>
<div
class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-empty x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="SignUpPage_LastName" data-xid="623" id="SignUpPage_LastName" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-1279" id="ext-element-1281"><span class="x-label-text-el" id="ext-element-1282">Last
Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1280">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1283"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1279" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-1282" aria-required="true" autocomplete="on" name="LastName" aria-readonly="false" data-componentid="SignUpPage_LastName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1284"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1285"></div>
</div>
</div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="SignUpPage_Email" data-xid="624" id="SignUpPage_Email"><label class="x-label-el" for="ext-element-1286" id="ext-element-1288"><span class="x-label-text-el" id="ext-element-1289">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1287">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1290"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-1286" maxlength="80" autocorrect="off"
aria-labelledby="ext-element-1289" aria-required="true" autocomplete="on" name="Email" aria-readonly="false" data-componentid="SignUpPage_Email" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1291"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1292"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="SignUpPage_Password" data-xid="625" id="SignUpPage_Password"><label class="x-label-el" for="ext-element-1293" id="ext-element-1295"><span class="x-label-text-el" id="ext-element-1296">Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1294">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1297"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-1293" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-1296" aria-required="true" autocomplete="on" name="Password" autocapitalize="off" aria-readonly="false" data-componentid="SignUpPage_Password" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1298">
<div data-componentid="ext-revealtrigger-4" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="626" id="ext-revealtrigger-4">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1299"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="SignUpPage_PasswordVisualizerChecklist" class="x-container x-component x-hidden x-hidden-display x-layout-auto-item" data-xid="627" id="SignUpPage_PasswordVisualizerChecklist">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1300">
<div data-componentid="SignUpPage_label_1" class="x-component x-label x-layout-auto-item" data-xid="628" id="SignUpPage_label_1">
<div class="x-innerhtml" id="ext-element-1301">Password must:</div>
</div>
<div data-componentid="SignUpPage_container_10" class="x-container x-component x-layout-auto-item" data-xid="629" id="SignUpPage_container_10">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1302">
<div data-componentid="SignUpPage_8charsIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="630" id="SignUpPage_8charsIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1303"></div>
</div>
<div data-componentid="SignUpPage_8charsLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="631" id="SignUpPage_8charsLabel">
<div class="x-innerhtml" id="ext-element-1304">Contain at least 8 characters</div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_CharacterTypes" class="x-component x-label RedLabel x-layout-auto-item" data-xid="632" id="SignUpPage_CharacterTypes">
<div class="x-innerhtml" id="ext-element-1305">Contain at least 3 of the following 4 characters:</div>
</div>
<div data-componentid="SignUpPage_container_11" class="x-container x-component x-layout-auto-item" data-xid="633" id="SignUpPage_container_11">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1306">
<div data-componentid="SignUpPage_lowerCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="634" id="SignUpPage_lowerCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1307"></div>
</div>
<div data-componentid="SignUpPage_lowerCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="635" id="SignUpPage_lowerCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-1308">1 lowercase letter</div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_container_12" class="x-container x-component x-layout-auto-item" data-xid="636" id="SignUpPage_container_12">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1309">
<div data-componentid="SignUpPage_upperCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="637" id="SignUpPage_upperCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1310"></div>
</div>
<div data-componentid="SignUpPage_upperCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="638" id="SignUpPage_upperCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-1311">1 uppercase letter</div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_container_13" class="x-container x-component x-layout-auto-item" data-xid="639" id="SignUpPage_container_13">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1312">
<div data-componentid="SignUpPage_oneNumberIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="640" id="SignUpPage_oneNumberIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1313"></div>
</div>
<div data-componentid="SignUpPage_oneNumberLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="641" id="SignUpPage_oneNumberLabel">
<div class="x-innerhtml" id="ext-element-1314">1 number</div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_container_14" class="x-container x-component x-layout-auto-item" data-xid="642" id="SignUpPage_container_14">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1315">
<div data-componentid="SignUpPage_OneSymbolIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="643" id="SignUpPage_OneSymbolIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1316"></div>
</div>
<div data-componentid="SignUpPage_OneSymbolLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="644" id="SignUpPage_OneSymbolLabel">
<div class="x-innerhtml" id="ext-element-1317">1 special character</div>
</div>
</div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="SignUpPage_ConfirmNewPassword" data-xid="645" id="SignUpPage_ConfirmNewPassword"><label class="x-label-el" for="ext-element-1318" id="ext-element-1320"><span class="x-label-text-el" id="ext-element-1321">Confirm
Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1319">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1322"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-1318" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-1321" aria-required="true" autocomplete="on" name="ConfirmNewPassword" autocapitalize="off" aria-readonly="false" data-componentid="SignUpPage_ConfirmNewPassword" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1323">
<div data-componentid="ext-revealtrigger-5" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="646" id="ext-revealtrigger-5">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1324"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="SignUpPage_PushNotificationToken" data-xid="647" id="SignUpPage_PushNotificationToken"><label class="x-label-el" for="ext-element-1325" id="ext-element-1327"><span class="x-label-text-el"
id="ext-element-1328">PushNotificationToken</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1326"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-1325" aria-labelledby="ext-element-1328" aria-required="false"
name="PushNotificationToken" aria-readonly="false" data-componentid="SignUpPage_PushNotificationToken" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1329"></div>
</div>
</div>
</div>
<div data-componentid="SignUpPage_container_15" class="x-container x-component x-layout-auto-item" data-xid="648" id="SignUpPage_container_15" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1330"></div>
</div>
<div data-componentid="SignUpPage_container_16" class="x-container x-component x-layout-auto-item" data-xid="649" id="SignUpPage_container_16">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-1331">
<div onclick="return Ext.doEv(this, event);" data-componentid="SignUpPage_button_SignUp"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="650" id="SignUpPage_button_SignUp">
<div class="x-inner-el" id="ext-element-1334">
<div class="x-body-el" id="ext-element-1333">
<div class="x-icon-el x-font-icon" id="ext-element-1336"></div>
<div class="x-text-el" id="ext-element-1335">Sign Up</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1332" aria-labelledby="ext-element-1335"
data-componentid="SignUpPage_button_SignUp"></button>
</div>
</div>
</div>
<div data-componentid="SignUpPage_container_17" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="651" id="SignUpPage_container_17">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-1337">
<div onclick="return Ext.doEv(this, event);" data-componentid="SignUpPage_button_Back"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="652" id="SignUpPage_button_Back">
<div class="x-inner-el" id="ext-element-1340">
<div class="x-body-el" id="ext-element-1339">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-1342" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-1341">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1338" aria-labelledby="ext-element-1341"
data-componentid="SignUpPage_button_Back"></button>
</div>
<div data-componentid="SignUpPage_spacer_6" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="653" id="SignUpPage_spacer_6" style="flex: 1 1 0%;"></div>
<div data-componentid="SignUpPage_container_18" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="654" id="SignUpPage_container_18">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1343">
<div data-componentid="SignUpPage_label_2" class="x-component x-label top-pad-8 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-auto-item" data-xid="655"
id="SignUpPage_label_2">
<div class="x-innerhtml" id="ext-element-1344">
<div class="im-underbutton-container-right">Already have an account? <a href="javascript:PerformAction({}, PatientPortalLoginController.redirectToLoginEmailForm);" class="im-link-underline-none im-default-link">Log in</a></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="FormSecurityQeustions"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="728" id="FormSecurityQeustions">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-1532">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-1469">
<div data-componentid="ValidationSummary_8" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="729" id="ValidationSummary_8">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-1470"></div>
<div id="ext-element-1471"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="FormSecurityQeustions_instamedHeading1" data-xid="730" id="FormSecurityQeustions_instamedHeading1">
<div class="x-body-el" id="ext-element-1472">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-1473" data-title="Set Up Security Questions">Set Up Security Questions</h1>
</div>
</div>
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-empty x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-trigger-field x-size-monitored x-paint-monitored x-layout-auto-item"
data-componentid="FormSecurityQeustions_ChallengeQuestion1" data-xid="731" id="FormSecurityQeustions_ChallengeQuestion1"><label class="x-label-el" for="ext-element-1474" id="ext-element-1476"><span class="x-label-text-el"
id="ext-element-1479">Question 1</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1475">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1477"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1474" aria-readonly="false" aria-labelledby="ext-element-1479"
placeholder="Select One" aria-required="true" autocomplete="on" name="ChallengeQuestion1" data-componentid="FormSecurityQeustions_ChallengeQuestion1" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1478">
<div data-componentid="ext-expandtrigger-6" class="x-expandtrigger x-trigger x-interactive" data-xid="732" id="ext-expandtrigger-6">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1480"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="FormSecurityQeustions_SecretAnswer1" data-xid="733" id="FormSecurityQeustions_SecretAnswer1"><label class="x-label-el" for="ext-element-1481" id="ext-element-1483"><span class="x-label-text-el" id="ext-element-1484">Secret
Answer for Question 1</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1482">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1485"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1481" maxlength="1000" autocorrect="off"
aria-labelledby="ext-element-1484" aria-required="true" autocomplete="on" name="SecretAnswer1" aria-readonly="false" data-componentid="FormSecurityQeustions_SecretAnswer1" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1486"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1487"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-empty x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-trigger-field x-size-monitored x-paint-monitored x-layout-auto-item"
data-componentid="FormSecurityQeustions_ChallengeQuestion2" data-xid="734" id="FormSecurityQeustions_ChallengeQuestion2"><label class="x-label-el" for="ext-element-1488" id="ext-element-1490"><span class="x-label-text-el"
id="ext-element-1493">Question 2</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1489">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1491"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1488" aria-readonly="false" aria-labelledby="ext-element-1493"
placeholder="Select One" aria-required="true" autocomplete="on" name="ChallengeQuestion2" data-componentid="FormSecurityQeustions_ChallengeQuestion2" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1492">
<div data-componentid="ext-expandtrigger-7" class="x-expandtrigger x-trigger x-interactive" data-xid="735" id="ext-expandtrigger-7">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1494"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="FormSecurityQeustions_SecretAnswer2" data-xid="736" id="FormSecurityQeustions_SecretAnswer2"><label class="x-label-el" for="ext-element-1495" id="ext-element-1497"><span class="x-label-text-el" id="ext-element-1498">Secret
Answer for Question 2</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1496">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1499"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1495" maxlength="1000" autocorrect="off"
aria-labelledby="ext-element-1498" aria-required="true" autocomplete="on" name="SecretAnswer2" aria-readonly="false" data-componentid="FormSecurityQeustions_SecretAnswer2" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1500"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1501"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-selectfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-empty x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-trigger-field x-size-monitored x-paint-monitored x-layout-auto-item"
data-componentid="FormSecurityQeustions_ChallengeQuestion3" data-xid="737" id="FormSecurityQeustions_ChallengeQuestion3"><label class="x-label-el" for="ext-element-1502" id="ext-element-1504"><span class="x-label-text-el"
id="ext-element-1507">Question 3</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1503">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1505"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1502" aria-readonly="false" aria-labelledby="ext-element-1507"
placeholder="Select One" aria-required="true" autocomplete="on" name="ChallengeQuestion3" data-componentid="FormSecurityQeustions_ChallengeQuestion3" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1506">
<div data-componentid="ext-expandtrigger-8" class="x-expandtrigger x-trigger x-interactive" data-xid="738" id="ext-expandtrigger-8">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1508"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="FormSecurityQeustions_SecretAnswer3" data-xid="739" id="FormSecurityQeustions_SecretAnswer3"><label class="x-label-el" for="ext-element-1509" id="ext-element-1511"><span class="x-label-text-el" id="ext-element-1512">Secret
Answer for Question 3</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1510">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1513"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1509" maxlength="1000" autocorrect="off"
aria-labelledby="ext-element-1512" aria-required="true" autocomplete="on" name="SecretAnswer3" aria-readonly="false" data-componentid="FormSecurityQeustions_SecretAnswer3" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1514"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1515"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="FormSecurityQeustions_UIAction" data-xid="740" id="FormSecurityQeustions_UIAction"><label class="x-label-el" for="ext-element-1516" id="ext-element-1518"><span class="x-label-text-el"
id="ext-element-1519">UIAction</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1517"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-1516" aria-labelledby="ext-element-1519" value="SignUpPage" aria-required="false"
name="UIAction" aria-readonly="false" data-componentid="FormSecurityQeustions_UIAction" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1520"></div>
</div>
</div>
</div>
<div data-componentid="FormSecurityQeustions_container" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="741" id="FormSecurityQeustions_container">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-1521">
<div data-componentid="FormSecurityQeustions_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="742" id="FormSecurityQeustions_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="FormSecurityQeustions_button_Back"
class="x-component x-button x-has-text secondary noprint x-icon-align-left x-arrow-align-right x-button-secondary x-component-secondary x-layout-box-item x-layout-hbox-item" data-xid="743" id="FormSecurityQeustions_button_Back">
<div class="x-inner-el" id="ext-element-1524">
<div class="x-body-el" id="ext-element-1523">
<div class="x-icon-el x-font-icon" id="ext-element-1526"></div>
<div class="x-text-el" id="ext-element-1525">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1522" aria-labelledby="ext-element-1525"
data-componentid="FormSecurityQeustions_button_Back"></button>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="FormSecurityQeustions_button_Save"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="744" id="FormSecurityQeustions_button_Save">
<div class="x-inner-el" id="ext-element-1529">
<div class="x-body-el" id="ext-element-1528">
<div class="x-icon-el x-font-icon" id="ext-element-1531"></div>
<div class="x-text-el" id="ext-element-1530">Save</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1527" aria-labelledby="ext-element-1530"
data-componentid="FormSecurityQeustions_button_Save"></button>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="RequestPasswordReset_1"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="810" id="RequestPasswordReset_1">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-1685">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-1651">
<div data-componentid="ValidationSummary_9" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="811" id="ValidationSummary_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-1652"></div>
<div id="ext-element-1653"></div>
</div>
<div data-componentid="RequestPasswordReset_container_11" class="x-container x-component x-layout-auto-item" data-xid="812" id="RequestPasswordReset_container_11" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1654"></div>
</div>
<div data-componentid="RequestPasswordReset_container_12" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="813" id="RequestPasswordReset_container_12">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1655">
<div data-componentid="RequestPasswordReset_spacer_7" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="814" id="RequestPasswordReset_spacer_7" style="flex: 1 1 0%;"></div>
<div data-componentid="RequestPasswordReset_container_13" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="815" id="RequestPasswordReset_container_13">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1656">
<div class="x-innerhtml" id="ext-element-1657"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_spacer_8" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="816" id="RequestPasswordReset_spacer_8" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_14" class="x-container x-component x-layout-auto-item" data-xid="817" id="RequestPasswordReset_container_14" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1658"></div>
</div>
<div data-componentid="RequestPasswordReset_container_15" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="818" id="RequestPasswordReset_container_15">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1659">
<div data-componentid="RequestPasswordReset_spacer_9" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="819" id="RequestPasswordReset_spacer_9" style="flex: 1 1 0%;"></div>
<div data-componentid="RequestPasswordReset_instamedLabelHeading1_1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="820"
id="RequestPasswordReset_instamedLabelHeading1_1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-1660">Forgot Password</h1>
</div>
<div data-componentid="RequestPasswordReset_spacer_10" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="821" id="RequestPasswordReset_spacer_10" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_16" class="x-container x-component x-layout-auto-item" data-xid="822" id="RequestPasswordReset_container_16" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1661"></div>
</div>
<div data-componentid="RequestPasswordReset_container_17" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="823" id="RequestPasswordReset_container_17">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-1662">
<div data-componentid="RequestPasswordReset_spacer_11" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="824" id="RequestPasswordReset_spacer_11" style="flex: 1 1 0%;"></div>
<div data-componentid="RequestPasswordReset_ForgotPasswordEnterEmail_1"
class="x-component x-label im-font-500 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item" data-xid="825"
id="RequestPasswordReset_ForgotPasswordEnterEmail_1">
<div class="x-innerhtml" id="ext-element-1663">Please enter the email address associated with your account. If you do not remember the email used, please contact <a href="tel:8664678263">(866) 467-8263</a>.</div>
</div>
<div data-componentid="RequestPasswordReset_spacer_12" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="826" id="RequestPasswordReset_spacer_12" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_18" class="x-container x-component x-layout-auto-item" data-xid="827" id="RequestPasswordReset_container_18" style="min-height: 20px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1664"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="RequestPasswordReset_Email_1" data-xid="828" id="RequestPasswordReset_Email_1"><label class="x-label-el" for="ext-element-1665" id="ext-element-1667"><span class="x-label-text-el" id="ext-element-1668">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1666">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1669"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-1665" maxlength="200" autocorrect="off"
aria-labelledby="ext-element-1668" aria-required="true" autocomplete="on" name="Email" aria-readonly="false" data-componentid="RequestPasswordReset_Email_1" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1670"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1671"></div>
</div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_19" class="x-container x-component x-layout-auto-item" data-xid="829" id="RequestPasswordReset_container_19" style="min-height: 12px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1672"></div>
</div>
<div data-componentid="RequestPasswordReset_container_20" class="x-container x-component x-layout-auto-item" data-xid="830" id="RequestPasswordReset_container_20">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-1673">
<div onclick="return Ext.doEv(this, event);" data-componentid="RequestPasswordReset_button_Next_1"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="831"
id="RequestPasswordReset_button_Next_1">
<div class="x-inner-el" id="ext-element-1676">
<div class="x-body-el" id="ext-element-1675">
<div class="x-icon-el x-font-icon" id="ext-element-1678"></div>
<div class="x-text-el" id="ext-element-1677">Next</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1674" aria-labelledby="ext-element-1677"
data-componentid="RequestPasswordReset_button_Next_1"></button>
</div>
</div>
</div>
<div data-componentid="RequestPasswordReset_container_21" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="832" id="RequestPasswordReset_container_21">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-1679">
<div onclick="return Ext.doEv(this, event);" data-componentid="RequestPasswordReset_button_Back_1"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="833"
id="RequestPasswordReset_button_Back_1">
<div class="x-inner-el" id="ext-element-1682">
<div class="x-body-el" id="ext-element-1681">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-1684" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-1683">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1680" aria-labelledby="ext-element-1683"
data-componentid="RequestPasswordReset_button_Back_1"></button>
</div>
<div data-componentid="RequestPasswordReset_spacer_13" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="834" id="RequestPasswordReset_spacer_13" style="flex: 1 1 0%;"></div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="DualLoginSignUp"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="900" id="DualLoginSignUp">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-1919">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-1804">
<div data-componentid="ValidationSummary_10" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="901" id="ValidationSummary_10">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-1805"></div>
<div id="ext-element-1806"></div>
</div>
<div class="x-unselectable x-paneltitle x-component x-text-align-left x-icon-align-left x-horizontal x-layout-auto-item" data-componentid="DualLoginSignUp_instamedHeading1" data-xid="902" id="DualLoginSignUp_instamedHeading1">
<div class="x-body-el" id="ext-element-1807">
<div class="x-icon-el x-font-icon"></div>
<h1 class="x-text-el instamed-heading1" id="ext-element-1808" data-title="Please Log In or Sign Up">Please Log In or Sign Up</h1>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-required x-error-target-under x-layout-auto-item"
data-componentid="DualLoginSignUp_DualLoginSignUpSelectedType" data-xid="903" id="DualLoginSignUp_DualLoginSignUpSelectedType"><label class="x-label-el" for="ext-element-1809" id="ext-element-1811"><span class="x-label-text-el"
id="ext-element-1812">DualLoginSignUpSelectedType</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1810"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-1809" aria-labelledby="ext-element-1812" value="LoginFieldsContainer"
aria-required="true" name="DualLoginSignUpSelectedType" aria-readonly="false" data-componentid="DualLoginSignUp_DualLoginSignUpSelectedType" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1813"></div>
</div>
</div>
</div>
<div id="DualLoginSignUp_radiogroup_" data-componentid="DualLoginSignUp_radiogroup_" class="x-segmentedbutton x-container x-component x-horizontal x-layout-auto-item" data-xid="904">
<div class="x-body-el x-segmentedbutton-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-1814">
<div onclick="return Ext.doEv(this, event);" data-componentid="button_LogIn"
class="x-component x-button x-has-text x-pressed noprint x-icon-align-left x-arrow-align-right x-button-segmented x-component-segmented x-layout-box-item x-layout-hbox-item x-flexed x-first" data-xid="905" id="button_LogIn"
style="flex: 1 1 0%;">
<div class="x-inner-el" id="ext-element-1817">
<div class="x-body-el" id="ext-element-1816">
<div class="x-icon-el x-font-icon" id="ext-element-1819"></div>
<div class="x-text-el" id="ext-element-1818">Log In</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1815" aria-labelledby="ext-element-1818"
data-componentid="button_LogIn"></button>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="button_SignUp"
class="x-component x-button x-has-text noprint x-icon-align-left x-arrow-align-right x-button-segmented x-component-segmented x-layout-box-item x-layout-hbox-item x-flexed x-last" data-xid="906" id="button_SignUp" style="flex: 1 1 0%;">
<div class="x-inner-el" id="ext-element-1822">
<div class="x-body-el" id="ext-element-1821">
<div class="x-icon-el x-font-icon" id="ext-element-1824"></div>
<div class="x-text-el" id="ext-element-1823">Sign Up</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1820" aria-labelledby="ext-element-1823"
data-componentid="button_SignUp"></button>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_LoginFieldsContainer" class="x-container x-component x-layout-auto-item" data-xid="907" id="DualLoginSignUp_LoginFieldsContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1825">
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-empty x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-layout-auto-item"
data-componentid="DualLoginSignUp_LoginEmail" data-xid="908" id="DualLoginSignUp_LoginEmail"><label class="x-label-el" for="ext-element-1826" id="ext-element-1828"><span class="x-label-text-el" id="ext-element-1829">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1827">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1830"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-1826" maxlength="200" autocorrect="off"
aria-labelledby="ext-element-1829" aria-required="true" autocomplete="on" name="LoginEmail" aria-readonly="false" data-componentid="DualLoginSignUp_LoginEmail" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1831"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1832"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="DualLoginSignUp_LoginPassword" data-xid="909" id="DualLoginSignUp_LoginPassword"><label class="x-label-el" for="ext-element-1833" id="ext-element-1835"><span class="x-label-text-el"
id="ext-element-1836">Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1834">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1837"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-1833" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-1836" aria-required="true" autocomplete="on" name="LoginPassword" autocapitalize="off" aria-readonly="false" data-componentid="DualLoginSignUp_LoginPassword" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1838">
<div data-componentid="ext-revealtrigger-6" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="910" id="ext-revealtrigger-6">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1839"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_SignUpFieldsContainer" class="x-container x-component x-hidden x-hidden-display x-layout-auto-item" data-xid="911" id="DualLoginSignUp_SignUpFieldsContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1840">
<div data-componentid="DualLoginSignUp_container" class="x-container x-component MultipleFieldsContainer x-layout-auto-item" data-xid="912" id="DualLoginSignUp_container">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-1841">
<div
class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-empty x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="DualLoginSignUp_FirstName" data-xid="913" id="DualLoginSignUp_FirstName" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-1842" id="ext-element-1844"><span class="x-label-text-el"
id="ext-element-1845">First Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1843">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1846"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1842" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-1845" aria-required="true" autocomplete="on" name="FirstName" aria-readonly="false" data-componentid="DualLoginSignUp_FirstName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1847"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1848"></div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_FirstNameLastNameSpacer" class="x-container x-component x-widthed x-spacer x-layout-box-item x-layout-hbox-item" data-xid="914" id="DualLoginSignUp_FirstNameLastNameSpacer" style="width: 24px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1849"></div>
</div>
<div
class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-empty x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-layout-box-item x-layout-hbox-item x-flexed"
data-componentid="DualLoginSignUp_LastName" data-xid="915" id="DualLoginSignUp_LastName" style="flex: 1 1 0%;"><label class="x-label-el" for="ext-element-1850" id="ext-element-1852"><span class="x-label-text-el"
id="ext-element-1853">Last Name</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1851">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1854"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-1850" maxlength="100" autocorrect="off"
aria-labelledby="ext-element-1853" aria-required="true" autocomplete="on" name="LastName" aria-readonly="false" data-componentid="DualLoginSignUp_LastName" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1855"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1856"></div>
</div>
</div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-empty x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-layout-auto-item"
data-componentid="DualLoginSignUp_Email" data-xid="916" id="DualLoginSignUp_Email"><label class="x-label-el" for="ext-element-1857" id="ext-element-1859"><span class="x-label-text-el" id="ext-element-1860">Email</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1858">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1861"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="email" id="ext-element-1857" maxlength="80" autocorrect="off"
aria-labelledby="ext-element-1860" aria-required="true" autocomplete="on" name="Email" aria-readonly="false" data-componentid="DualLoginSignUp_Email" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1862"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1863"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="DualLoginSignUp_Password" data-xid="917" id="DualLoginSignUp_Password"><label class="x-label-el" for="ext-element-1864" id="ext-element-1866"><span class="x-label-text-el" id="ext-element-1867">Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1865">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1868"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-1864" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-1867" aria-required="true" autocomplete="on" name="Password" autocapitalize="off" aria-readonly="false" data-componentid="DualLoginSignUp_Password" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1869">
<div data-componentid="ext-revealtrigger-7" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="918" id="ext-revealtrigger-7">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1870"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="DualLoginSignUp_PasswordVisualizerChecklist" class="x-container x-component x-hidden x-hidden-display x-layout-auto-item" data-xid="919" id="DualLoginSignUp_PasswordVisualizerChecklist">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1871">
<div data-componentid="DualLoginSignUp_label" class="x-component x-label x-layout-auto-item" data-xid="920" id="DualLoginSignUp_label">
<div class="x-innerhtml" id="ext-element-1872">Password must:</div>
</div>
<div data-componentid="DualLoginSignUp_container_1" class="x-container x-component x-layout-auto-item" data-xid="921" id="DualLoginSignUp_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1873">
<div data-componentid="DualLoginSignUp_8charsIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="922" id="DualLoginSignUp_8charsIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1874"></div>
</div>
<div data-componentid="DualLoginSignUp_8charsLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="923" id="DualLoginSignUp_8charsLabel">
<div class="x-innerhtml" id="ext-element-1875">Contain at least 8 characters</div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_CharacterTypes" class="x-component x-label RedLabel x-layout-auto-item" data-xid="924" id="DualLoginSignUp_CharacterTypes">
<div class="x-innerhtml" id="ext-element-1876">Contain at least 3 of the following 4 characters:</div>
</div>
<div data-componentid="DualLoginSignUp_container_2" class="x-container x-component x-layout-auto-item" data-xid="925" id="DualLoginSignUp_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1877">
<div data-componentid="DualLoginSignUp_lowerCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="926" id="DualLoginSignUp_lowerCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1878"></div>
</div>
<div data-componentid="DualLoginSignUp_lowerCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="927" id="DualLoginSignUp_lowerCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-1879">1 lowercase letter</div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_container_3" class="x-container x-component x-layout-auto-item" data-xid="928" id="DualLoginSignUp_container_3">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1880">
<div data-componentid="DualLoginSignUp_upperCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="929" id="DualLoginSignUp_upperCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1881"></div>
</div>
<div data-componentid="DualLoginSignUp_upperCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="930" id="DualLoginSignUp_upperCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-1882">1 uppercase letter</div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_container_4" class="x-container x-component x-layout-auto-item" data-xid="931" id="DualLoginSignUp_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1883">
<div data-componentid="DualLoginSignUp_oneNumberIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="932" id="DualLoginSignUp_oneNumberIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1884"></div>
</div>
<div data-componentid="DualLoginSignUp_oneNumberLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="933" id="DualLoginSignUp_oneNumberLabel">
<div class="x-innerhtml" id="ext-element-1885">1 number</div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_container_5" class="x-container x-component x-layout-auto-item" data-xid="934" id="DualLoginSignUp_container_5">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-1886">
<div data-componentid="DualLoginSignUp_OneSymbolIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="935" id="DualLoginSignUp_OneSymbolIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-1887"></div>
</div>
<div data-componentid="DualLoginSignUp_OneSymbolLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="936" id="DualLoginSignUp_OneSymbolLabel">
<div class="x-innerhtml" id="ext-element-1888">1 special character</div>
</div>
</div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="DualLoginSignUp_ConfirmNewPassword" data-xid="937" id="DualLoginSignUp_ConfirmNewPassword"><label class="x-label-el" for="ext-element-1889" id="ext-element-1891"><span class="x-label-text-el"
id="ext-element-1892">Confirm Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-1890">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-1893"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-1889" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-1892" aria-required="true" autocomplete="on" name="ConfirmNewPassword" autocapitalize="off" aria-readonly="false" data-componentid="DualLoginSignUp_ConfirmNewPassword" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-1894">
<div data-componentid="ext-revealtrigger-8" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="938" id="ext-revealtrigger-8">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-1895"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_container_6" class="x-container x-component im-overflow-visible-container x-layout-auto-item" data-xid="939" id="DualLoginSignUp_container_6">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-1896">
<div data-componentid="DualLoginSignUp_LoginButtonsContainer" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="940" id="DualLoginSignUp_LoginButtonsContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-1897">
<div onclick="return Ext.doEv(this, event);" data-componentid="DualLoginSignUp_button_ForgotPassword"
class="x-component x-button x-has-text x-button-link-style blue noprint x-icon-align-left x-arrow-align-right x-button-blue x-component-blue x-layout-box-item x-layout-hbox-item" data-xid="941"
id="DualLoginSignUp_button_ForgotPassword">
<div class="x-inner-el" id="ext-element-1900">
<div class="x-body-el" id="ext-element-1899">
<div class="x-icon-el x-font-icon" id="ext-element-1902"></div>
<div class="x-text-el" id="ext-element-1901">Forgot Password?</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1898" aria-labelledby="ext-element-1901"
data-componentid="DualLoginSignUp_button_ForgotPassword"></button>
</div>
<div data-componentid="DualLoginSignUp_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="942" id="DualLoginSignUp_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="DualLoginSignUp_button_LogIn"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="943" id="DualLoginSignUp_button_LogIn">
<div class="x-inner-el" id="ext-element-1905">
<div class="x-body-el" id="ext-element-1904">
<div class="x-icon-el x-font-icon" id="ext-element-1907"></div>
<div class="x-text-el" id="ext-element-1906">Log In</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1903" aria-labelledby="ext-element-1906"
data-componentid="DualLoginSignUp_button_LogIn"></button>
</div>
</div>
</div>
<div data-componentid="DualLoginSignUp_SignUpButtonsContainer" class="x-container x-component x-hidden x-hidden-display buttonContainer x-layout-auto-item" data-xid="944" id="DualLoginSignUp_SignUpButtonsContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-1908">
<div onclick="return Ext.doEv(this, event);" data-componentid="DualLoginSignUp_button_SkipToReceipt"
class="x-component x-button x-has-text x-hidden x-hidden-display noprint x-icon-align-left x-arrow-align-right x-layout-box-item x-layout-hbox-item" data-xid="945" id="DualLoginSignUp_button_SkipToReceipt">
<div class="x-inner-el" id="ext-element-1911">
<div class="x-body-el" id="ext-element-1910">
<div class="x-icon-el x-font-icon" id="ext-element-1913"></div>
<div class="x-text-el" id="ext-element-1912">Skip To Receipt</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1909" aria-labelledby="ext-element-1912"
data-componentid="DualLoginSignUp_button_SkipToReceipt"></button>
</div>
<div data-componentid="DualLoginSignUp_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="946" id="DualLoginSignUp_spacer_1" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="DualLoginSignUp_button_SignUp"
class="x-component x-button x-has-text action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-hbox-item" data-xid="947" id="DualLoginSignUp_button_SignUp">
<div class="x-inner-el" id="ext-element-1916">
<div class="x-body-el" id="ext-element-1915">
<div class="x-icon-el x-font-icon" id="ext-element-1918"></div>
<div class="x-text-el" id="ext-element-1917">Sign Up</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-1914" aria-labelledby="ext-element-1917"
data-componentid="DualLoginSignUp_button_SignUp"></button>
</div>
</div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="TwoFactorVerifyScreen"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="1013" id="TwoFactorVerifyScreen">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-2104">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-2038">
<div data-componentid="ValidationSummary_11" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="1014" id="ValidationSummary_11">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-2039"></div>
<div id="ext-element-2040"></div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container" class="x-container x-component x-layout-auto-item" data-xid="1015" id="TwoFactorVerifyScreen_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2041"></div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1016" id="TwoFactorVerifyScreen_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2042">
<div data-componentid="TwoFactorVerifyScreen_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1017" id="TwoFactorVerifyScreen_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="TwoFactorVerifyScreen_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="1018" id="TwoFactorVerifyScreen_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2043">
<div class="x-innerhtml" id="ext-element-2044"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1019" id="TwoFactorVerifyScreen_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_3" class="x-container x-component x-layout-auto-item" data-xid="1020" id="TwoFactorVerifyScreen_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2045"></div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_4" class="x-container x-component horizontalCentering text-center x-layout-auto-item" data-xid="1021" id="TwoFactorVerifyScreen_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-align-center x-layout-vbox x-vertical" id="ext-element-2046">
<div id="TwoFactorVerifyScreen_image" data-componentid="TwoFactorVerifyScreen_image" class="x-component x-img x-img-background im-single-form-image x-layout-box-item x-layout-vbox-item" data-xid="1022"
style="background-image: url("https://cdn.instamed.com/V_2024_May/Content/Images/PaymentPortal/ppp-2fa-code-min.svg");"></div>
<div data-componentid="TwoFactorVerifyScreen_container_5" class="x-container x-component x-center-helper x-layout-box-item x-layout-vbox-item" data-xid="1023" id="TwoFactorVerifyScreen_container_5">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2047">
<div data-componentid="TwoFactorVerifyScreen_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1024" id="TwoFactorVerifyScreen_spacer_2" style="flex: 1 1 0%;"></div>
<div data-componentid="TwoFactorVerifyScreen_instamedLabelHeading1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="1025"
id="TwoFactorVerifyScreen_instamedLabelHeading1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-2048">Two-Step Verification Required</h1>
</div>
<div data-componentid="TwoFactorVerifyScreen_spacer_3" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1026" id="TwoFactorVerifyScreen_spacer_3" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_6" class="x-container x-component x-layout-box-item x-layout-vbox-item" data-xid="1027" id="TwoFactorVerifyScreen_container_6" style="min-height: 20px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2049"></div>
</div>
<div data-componentid="TwoFactorVerifyScreen_TwoFactorVerify" class="x-container x-component im-form-bodytext x-layout-box-item x-layout-vbox-item" data-xid="1028" id="TwoFactorVerifyScreen_TwoFactorVerify">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2050">
<div class="x-innerhtml" id="ext-element-2051">You are enrolled in two-step verification when accessing your account from a new device or browser. We have texted your phone number on file </div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_7" class="x-container x-component x-layout-box-item x-layout-vbox-item" data-xid="1029" id="TwoFactorVerifyScreen_container_7" style="min-height: 16px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2052"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="TwoFactorVerifyScreen_VerificationCode" data-xid="1030" id="TwoFactorVerifyScreen_VerificationCode" style="min-width: 256px;"><label class="x-label-el" for="ext-element-2053" id="ext-element-2055"><span
class="x-label-text-el" id="ext-element-2056">Verification Code</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2054">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2057"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="number" id="ext-element-2053" maxlength="6" autocorrect="off"
aria-labelledby="ext-element-2056" pattern="[0-9]*" aria-required="true" autocomplete="off" name="VerificationCode" aria-readonly="false" data-componentid="TwoFactorVerifyScreen_VerificationCode" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2058"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2059"></div>
</div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_RememberThisDeviceCheckboxComponent" class="x-container x-component x-layout-auto-item" data-xid="1031" id="TwoFactorVerifyScreen_RememberThisDeviceCheckboxComponent">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-2060">
<div class="x-no-min-content x-checkboxfield x-field x-component x-body-align-start x-label-align-horizontal x-label-text-align-left x-checked x-label-align-right x-error-target-under x-paint-monitored x-layout-box-item x-layout-hbox-item"
id="TwoFactorVerifyScreen_RememberThisDevice" data-componentid="TwoFactorVerifyScreen_RememberThisDevice" data-xid="1032"><label class="x-label-el" id="ext-element-2063" for="ext-element-2061"><span class="x-label-text-el"
id="ext-element-2065"></span></label>
<div class="x-body-wrap-el" id="ext-element-2066">
<div class="x-body-el" id="ext-element-2062">
<div class="x-box-wrap-el" id="ext-element-2067">
<div class="x-box-el" id="ext-element-2068">
<div class="x-font-icon x-icon-el" id="ext-element-2069"><input tabindex="0" oninput="return Ext.doEv(this, event);" onchange="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-2061" type="checkbox" value="true"
aria-required="false" name="RememberThisDevice" aria-disabled="false" data-componentid="TwoFactorVerifyScreen_RememberThisDevice" aria-invalid="false"></div>
</div><label class="x-box-label-el" id="ext-element-2064" for="ext-element-2061"></label>
</div>
</div>
<div class="x-error-el" id="ext-element-2070">
<div class="x-error-icon-el x-font-icon" id="ext-element-2071"></div>
<div class="x-help-message-el" id="ext-element-2072"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="TwoFactorVerifyScreen_LabelRememberThisDevice" class="x-container x-component im-checkbox-label im-checkbox-label-single-field-form x-layout-box-item x-layout-hbox-item" data-xid="1033"
id="TwoFactorVerifyScreen_LabelRememberThisDevice">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2073">
<div class="x-innerhtml" id="ext-element-2074">Remember this device in the future</div>
</div>
</div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_8" class="x-container x-component x-layout-auto-item" data-xid="1034" id="TwoFactorVerifyScreen_container_8" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2075"></div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="TwoFactorVerifyScreen_Counter" data-xid="1035" id="TwoFactorVerifyScreen_Counter"><label class="x-label-el" for="ext-element-2076" id="ext-element-2078"><span class="x-label-text-el"
id="ext-element-2079">Counter</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2077"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2076" aria-labelledby="ext-element-2079" value="0" aria-required="false"
name="Counter" aria-readonly="false" data-componentid="TwoFactorVerifyScreen_Counter" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2080"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="TwoFactorVerifyScreen_LoginCounter" data-xid="1036" id="TwoFactorVerifyScreen_LoginCounter"><label class="x-label-el" for="ext-element-2081" id="ext-element-2083"><span class="x-label-text-el"
id="ext-element-2084">LoginCounter</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2082"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2081" aria-labelledby="ext-element-2084" value="0" aria-required="false"
name="LoginCounter" aria-readonly="false" data-componentid="TwoFactorVerifyScreen_LoginCounter" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2085"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="TwoFactorVerifyScreen_Flow" data-xid="1037" id="TwoFactorVerifyScreen_Flow"><label class="x-label-el" for="ext-element-2086" id="ext-element-2088"><span class="x-label-text-el" id="ext-element-2089">Flow</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2087"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2086" aria-labelledby="ext-element-2089" value="DualLogin" aria-required="false"
name="Flow" aria-readonly="false" data-componentid="TwoFactorVerifyScreen_Flow" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2090"></div>
</div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_9" class="x-container x-component x-layout-auto-item" data-xid="1038" id="TwoFactorVerifyScreen_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-2091">
<div onclick="return Ext.doEv(this, event);" data-componentid="TwoFactorVerifyScreen_button_Next"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="1039"
id="TwoFactorVerifyScreen_button_Next">
<div class="x-inner-el" id="ext-element-2094">
<div class="x-body-el" id="ext-element-2093">
<div class="x-icon-el x-font-icon" id="ext-element-2096"></div>
<div class="x-text-el" id="ext-element-2095">Next</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2092" aria-labelledby="ext-element-2095"
data-componentid="TwoFactorVerifyScreen_button_Next"></button>
</div>
</div>
</div>
<div data-componentid="TwoFactorVerifyScreen_container_10" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="1040" id="TwoFactorVerifyScreen_container_10">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-2097">
<div onclick="return Ext.doEv(this, event);" data-componentid="TwoFactorVerifyScreen_button_Back"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="1041"
id="TwoFactorVerifyScreen_button_Back">
<div class="x-inner-el" id="ext-element-2100">
<div class="x-body-el" id="ext-element-2099">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-2102" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-2101">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2098" aria-labelledby="ext-element-2101"
data-componentid="TwoFactorVerifyScreen_button_Back"></button>
</div>
<div data-componentid="TwoFactorVerifyScreen_spacer_4" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1042" id="TwoFactorVerifyScreen_spacer_4" style="flex: 1 1 0%;"></div>
<div data-componentid="TwoFactorVerifyScreen_ResendCode" class="x-component x-label top-pad-8 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item"
data-xid="1043" id="TwoFactorVerifyScreen_ResendCode">
<div class="x-innerhtml" id="ext-element-2103"><a href="javascript:PerformAction({}, PatientPortalLoginController.sendMobilePhoneNumberConfirmationCode);" class="im-link-underline-none im-default-link">Resend Code</a></div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="TextMsgEnrollScreen"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="1109" id="TextMsgEnrollScreen">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-2277">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-2223">
<div data-componentid="ValidationSummary_12" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="1110" id="ValidationSummary_12">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-2224"></div>
<div id="ext-element-2225"></div>
</div>
<div data-componentid="TextMsgEnrollScreen_container" class="x-container x-component x-layout-auto-item" data-xid="1111" id="TextMsgEnrollScreen_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2226"></div>
</div>
<div data-componentid="TextMsgEnrollScreen_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1112" id="TextMsgEnrollScreen_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2227">
<div data-componentid="TextMsgEnrollScreen_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1113" id="TextMsgEnrollScreen_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="TextMsgEnrollScreen_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="1114" id="TextMsgEnrollScreen_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2228">
<div class="x-innerhtml" id="ext-element-2229"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1115" id="TextMsgEnrollScreen_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_container_3" class="x-container x-component x-layout-auto-item" data-xid="1116" id="TextMsgEnrollScreen_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2230"></div>
</div>
<div data-componentid="TextMsgEnrollScreen_container_4" class="x-container x-component horizontalCentering text-center x-layout-auto-item" data-xid="1117" id="TextMsgEnrollScreen_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-align-center x-layout-vbox x-vertical" id="ext-element-2231">
<div data-componentid="TextMsgEnrollScreen_image" class="x-component x-img x-img-background im-single-form-image x-layout-box-item x-layout-vbox-item" data-xid="1118" id="TextMsgEnrollScreen_image"
style="background-image: url("https://cdn.instamed.com/V_2024_May/Content/Images/PaymentPortal/ppp_graphic_text.min.svg");"></div>
<div data-componentid="TextMsgEnrollScreen_container_5" class="x-container x-component x-layout-box-item x-layout-vbox-item" data-xid="1119" id="TextMsgEnrollScreen_container_5" style="min-height: 16px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2232"></div>
</div>
<div data-componentid="TextMsgEnrollScreen_instamedLabelHeading1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-vbox-item" data-xid="1120"
id="TextMsgEnrollScreen_instamedLabelHeading1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-2233">Keep Your Account Safe and Updated</h1>
</div>
<div data-componentid="TextMsgEnrollScreen_container_6" class="x-container x-component x-layout-box-item x-layout-vbox-item" data-xid="1121" id="TextMsgEnrollScreen_container_6" style="min-height: 26px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2234"></div>
</div>
<div data-componentid="TextMsgEnrollScreen_TextMsgTwoStepFactorAndText" class="x-container x-component im-form-bodytext x-layout-box-item x-layout-vbox-item" data-xid="1122" id="TextMsgEnrollScreen_TextMsgTwoStepFactorAndText">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2235">
<div class="x-innerhtml" id="ext-element-2236">To increase your security, please add and verify your mobile phone number. You can use this to reset passwords, enable two-step verification and enroll in payment alerts via text message.
</div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_TextMsgTwoStepFactorOnly" class="x-container x-component x-hidden x-hidden-display im-form-bodytext x-layout-box-item x-layout-vbox-item" data-xid="1123"
id="TextMsgEnrollScreen_TextMsgTwoStepFactorOnly">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2237">
<div class="x-innerhtml" id="ext-element-2238">To increase your security, please add and verify your mobile phone number. You can use this to reset passwords and enable two-step verification.</div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_container_7" class="x-container x-component x-layout-box-item x-layout-vbox-item" data-xid="1124" id="TextMsgEnrollScreen_container_7" style="min-height: 16px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2239"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="TextMsgEnrollScreen_MobilePhoneNumber2" data-xid="1125" id="TextMsgEnrollScreen_MobilePhoneNumber2"><label class="x-label-el" for="ext-element-2240" id="ext-element-2242"><span class="x-label-text-el"
id="ext-element-2243">Mobile Phone Number</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2241">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2244"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="tel" id="ext-element-2240" maxlength="14" autocorrect="off"
aria-labelledby="ext-element-2243" aria-required="true" autocomplete="on" name="MobilePhoneNumber2" aria-readonly="false" data-componentid="TextMsgEnrollScreen_MobilePhoneNumber2" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2245"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2246"></div>
</div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_EnableTwoStepCheckbox" class="x-container x-component x-layout-auto-item" data-xid="1126" id="TextMsgEnrollScreen_EnableTwoStepCheckbox">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-2247">
<div class="x-no-min-content x-checkboxfield x-field x-component x-body-align-start x-label-align-horizontal x-label-text-align-left x-checked x-label-align-right x-error-target-under x-paint-monitored x-layout-box-item x-layout-hbox-item"
data-componentid="TextMsgEnrollScreen_EnableTwoStepVerification" data-xid="1127" id="TextMsgEnrollScreen_EnableTwoStepVerification"><label class="x-label-el" for="ext-element-2248" id="ext-element-2250"><span class="x-label-text-el"
id="ext-element-2252"></span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2249">
<div class="x-box-wrap-el">
<div class="x-box-el">
<div class="x-font-icon x-icon-el"><input tabindex="0" oninput="return Ext.doEv(this, event);" onchange="return Ext.doEv(this, event);" class="x-input-el" type="checkbox" id="ext-element-2248" value="true" aria-required="false"
name="EnableTwoStepVerification" aria-disabled="false" data-componentid="TextMsgEnrollScreen_EnableTwoStepVerification" aria-invalid="false"></div>
</div><label class="x-box-label-el" for="ext-element-2248" id="ext-element-2251"></label>
</div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2253"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="TextMsgEnrollScreen_LabelEnableTwoStepVerification" class="x-container x-component im-checkbox-label im-checkbox-label-single-field-form x-layout-box-item x-layout-hbox-item" data-xid="1128"
id="TextMsgEnrollScreen_LabelEnableTwoStepVerification">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2254">
<div class="x-innerhtml" id="ext-element-2255">Enable Two-Step Verification</div>
</div>
</div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_TextMsgTwoStepTermsClause" class="x-container x-component im-form-bodytext x-layout-auto-item" data-xid="1129" id="TextMsgEnrollScreen_TextMsgTwoStepTermsClause">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2256">
<div class="x-innerhtml" id="ext-element-2257">By enrolling in two-step verification and/or text alerts, you agree to all InstaMed <a href="https://www.instamed.com/communications-terms-and-conditions/" target="_blank">Communications
Terms and Conditions</a>. InstaMed will only use this number for account security and payment alerts. Message and data rates may apply.</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="TextMsgEnrollScreen_EnrollInTextAlerts" data-xid="1130" id="TextMsgEnrollScreen_EnrollInTextAlerts"><label class="x-label-el" for="ext-element-2258" id="ext-element-2260"><span class="x-label-text-el"
id="ext-element-2261">EnrollInTextAlerts</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2259"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2258" aria-labelledby="ext-element-2261" value="true" aria-required="false"
name="EnrollInTextAlerts" aria-readonly="false" data-componentid="TextMsgEnrollScreen_EnrollInTextAlerts" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2262"></div>
</div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_container_8" class="x-container x-component x-layout-auto-item" data-xid="1131" id="TextMsgEnrollScreen_container_8">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-2263">
<div data-componentid="TextMsgEnrollScreen_container_9" class="x-container x-component x-layout-box-item x-layout-vbox-item" data-xid="1132" id="TextMsgEnrollScreen_container_9" style="min-height: 24px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2264"></div>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="TextMsgEnrollScreen_button_Verify"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="1133"
id="TextMsgEnrollScreen_button_Verify">
<div class="x-inner-el" id="ext-element-2267">
<div class="x-body-el" id="ext-element-2266">
<div class="x-icon-el x-font-icon" id="ext-element-2269"></div>
<div class="x-text-el" id="ext-element-2268">Verify</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2265" aria-labelledby="ext-element-2268"
data-componentid="TextMsgEnrollScreen_button_Verify"></button>
</div>
</div>
</div>
<div data-componentid="TextMsgEnrollScreen_container_10" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="1134" id="TextMsgEnrollScreen_container_10">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-2270">
<div onclick="return Ext.doEv(this, event);" data-componentid="TextMsgEnrollScreen_button_Back"
class="x-component x-button x-has-text x-has-icon x-hidden x-hidden-display Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="1135"
id="TextMsgEnrollScreen_button_Back">
<div class="x-inner-el" id="ext-element-2273">
<div class="x-body-el" id="ext-element-2272">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-2275" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-2274">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2271" aria-labelledby="ext-element-2274"
data-componentid="TextMsgEnrollScreen_button_Back"></button>
</div>
<div data-componentid="TextMsgEnrollScreen_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1136" id="TextMsgEnrollScreen_spacer_2" style="flex: 1 1 0%;"></div>
<div data-componentid="TextMsgEnrollScreen_TextEnrollSkip" class="x-component x-label top-pad-8 subheading-primary x-label-subheading-primary x-component-subheading-primary x-layout-box-item x-layout-hbox-item" data-xid="1137"
id="TextMsgEnrollScreen_TextEnrollSkip">
<div class="x-innerhtml" id="ext-element-2276"><a href="javascript:PerformAction({}, TextMessageEnrollmentController.skipTextEnrollment);" class="im-link-underline-none im-default-link">Skip</a></div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="ForgotPasswordSelectMethod"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="1203" id="ForgotPasswordSelectMethod">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-2448">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-2396">
<div data-componentid="ValidationSummary_13" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="1204" id="ValidationSummary_13">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-2397"></div>
<div id="ext-element-2398"></div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container" class="x-container x-component x-layout-auto-item" data-xid="1205" id="ForgotPasswordSelectMethod_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2399"></div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1206" id="ForgotPasswordSelectMethod_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2400">
<div data-componentid="ForgotPasswordSelectMethod_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1207" id="ForgotPasswordSelectMethod_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="ForgotPasswordSelectMethod_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="1208" id="ForgotPasswordSelectMethod_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2401">
<div class="x-innerhtml" id="ext-element-2402"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1209" id="ForgotPasswordSelectMethod_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_3" class="x-container x-component x-layout-auto-item" data-xid="1210" id="ForgotPasswordSelectMethod_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2403"></div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_4" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1211" id="ForgotPasswordSelectMethod_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2404">
<div data-componentid="ForgotPasswordSelectMethod_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1212" id="ForgotPasswordSelectMethod_spacer_2" style="flex: 1 1 0%;"></div>
<div data-componentid="ForgotPasswordSelectMethod_instamedLabelHeading1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="1213"
id="ForgotPasswordSelectMethod_instamedLabelHeading1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-2405">Forgot Password</h1>
</div>
<div data-componentid="ForgotPasswordSelectMethod_spacer_3" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1214" id="ForgotPasswordSelectMethod_spacer_3" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_5" class="x-container x-component x-layout-auto-item" data-xid="1215" id="ForgotPasswordSelectMethod_container_5" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2406"></div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_6" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1216" id="ForgotPasswordSelectMethod_container_6">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2407">
<div data-componentid="ForgotPasswordSelectMethod_spacer_4" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1217" id="ForgotPasswordSelectMethod_spacer_4" style="flex: 1 1 0%;"></div>
<div data-componentid="ForgotPasswordSelectMethod_ForgotPasswordSelectMethod"
class="x-component x-label im-font-500 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item" data-xid="1218"
id="ForgotPasswordSelectMethod_ForgotPasswordSelectMethod">
<div class="x-innerhtml" id="ext-element-2408">Please select a method to reset your password.</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_spacer_5" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1219" id="ForgotPasswordSelectMethod_spacer_5" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_7" class="x-container x-component x-layout-auto-item" data-xid="1220" id="ForgotPasswordSelectMethod_container_7" style="min-height: 20px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2409"></div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_8" class="x-container x-component x-layout-auto-item" data-xid="1221" id="ForgotPasswordSelectMethod_container_8">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-2410">
<div
class="x-no-min-content x-radiofield x-checkboxfield x-field x-component x-body-align-start x-label-align-horizontal x-label-text-align-left x-checked x-label-align-right x-error-target-under subheading-primary-inline x-radiofield-subheading-primary-inline x-checkboxfield-subheading-primary-inline x-field-subheading-primary-inline x-component-subheading-primary-inline x-layout-box-item x-layout-hbox-item"
id="ForgotPasswordSelectMethod_SelectPasswordResetMethod" data-componentid="ForgotPasswordSelectMethod_SelectPasswordResetMethod" data-xid="1222"><label class="x-label-el" id="ext-element-2413" for="ext-element-2411"><span
class="x-label-text-el" id="ext-element-2415"></span></label>
<div class="x-body-wrap-el" id="ext-element-2416">
<div class="x-body-el" id="ext-element-2412">
<div class="x-box-wrap-el" id="ext-element-2417">
<div class="x-box-el" id="ext-element-2418">
<div class="x-font-icon x-icon-el" id="ext-element-2419"><input tabindex="0" oninput="return Ext.doEv(this, event);" onchange="return Ext.doEv(this, event);" class="x-input-el" id="ext-element-2411" type="radio"
aria-labelledby="ext-element-2415" aria-required="false" name="SelectPasswordResetMethod" aria-disabled="false" data-componentid="ForgotPasswordSelectMethod_SelectPasswordResetMethod" aria-invalid="false"></div>
</div><label class="x-box-label-el" id="ext-element-2414" for="ext-element-2411"></label>
</div>
</div>
<div class="x-error-el" id="ext-element-2420">
<div class="x-error-icon-el x-font-icon" id="ext-element-2421"></div>
<div class="x-help-message-el" id="ext-element-2422"></div>
</div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_UserEmail" class="x-component x-label light-subheading-primary x-label-light-subheading-primary x-component-light-subheading-primary x-layout-box-item x-layout-hbox-item" data-xid="1223"
id="ForgotPasswordSelectMethod_UserEmail" style="padding: 29px 0px 0px !important;"></div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_9" class="x-container x-component x-layout-auto-item" data-xid="1224" id="ForgotPasswordSelectMethod_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-hbox x-horizontal x-align-stretch x-pack-start" id="ext-element-2423">
<div
class="x-no-min-content x-radiofield x-checkboxfield x-field x-component x-body-align-start x-label-align-horizontal x-label-text-align-left x-label-align-right x-error-target-under subheading-primary-inline x-radiofield-subheading-primary-inline x-checkboxfield-subheading-primary-inline x-field-subheading-primary-inline x-component-subheading-primary-inline x-layout-box-item x-layout-hbox-item"
data-componentid="ForgotPasswordSelectMethod_SelectPasswordResetMethod_1" data-xid="1225" id="ForgotPasswordSelectMethod_SelectPasswordResetMethod_1"><label class="x-label-el" for="ext-element-2424" id="ext-element-2426"><span
class="x-label-text-el" id="ext-element-2428"></span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2425">
<div class="x-box-wrap-el">
<div class="x-box-el">
<div class="x-font-icon x-icon-el"><input tabindex="0" oninput="return Ext.doEv(this, event);" onchange="return Ext.doEv(this, event);" class="x-input-el" type="radio" id="ext-element-2424" aria-labelledby="ext-element-2428"
aria-required="false" name="SelectPasswordResetMethod" aria-disabled="false" data-componentid="ForgotPasswordSelectMethod_SelectPasswordResetMethod_1" aria-invalid="false"></div>
</div><label class="x-box-label-el" for="ext-element-2424" id="ext-element-2427"></label>
</div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2429"></div>
</div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_UserMobilePhoneNumber" class="x-component x-label light-subheading-primary x-label-light-subheading-primary x-component-light-subheading-primary x-layout-box-item x-layout-hbox-item"
data-xid="1226" id="ForgotPasswordSelectMethod_UserMobilePhoneNumber" style="padding: 29px 0px 0px !important;"></div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-box-item x-layout-hbox-item"
data-componentid="ForgotPasswordSelectMethod_VerificationCodeMethod" data-xid="1227" id="ForgotPasswordSelectMethod_VerificationCodeMethod"><label class="x-label-el" for="ext-element-2430" id="ext-element-2432"><span
class="x-label-text-el" id="ext-element-2433">VerificationCodeMethod</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2431"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2430" aria-labelledby="ext-element-2433" value="Email" aria-required="false"
name="VerificationCodeMethod" aria-readonly="false" data-componentid="ForgotPasswordSelectMethod_VerificationCodeMethod" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2434"></div>
</div>
</div>
</div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_10" class="x-container x-component x-layout-auto-item" data-xid="1228" id="ForgotPasswordSelectMethod_container_10" style="min-height: 45px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2435"></div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_11" class="x-container x-component x-layout-auto-item" data-xid="1229" id="ForgotPasswordSelectMethod_container_11">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-2436">
<div onclick="return Ext.doEv(this, event);" data-componentid="ForgotPasswordSelectMethod_button_Reset"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="1230"
id="ForgotPasswordSelectMethod_button_Reset">
<div class="x-inner-el" id="ext-element-2439">
<div class="x-body-el" id="ext-element-2438">
<div class="x-icon-el x-font-icon" id="ext-element-2441"></div>
<div class="x-text-el" id="ext-element-2440">Reset</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2437" aria-labelledby="ext-element-2440"
data-componentid="ForgotPasswordSelectMethod_button_Reset"></button>
</div>
</div>
</div>
<div data-componentid="ForgotPasswordSelectMethod_container_12" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="1231" id="ForgotPasswordSelectMethod_container_12">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-2442">
<div onclick="return Ext.doEv(this, event);" data-componentid="ForgotPasswordSelectMethod_button_Back"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="1232"
id="ForgotPasswordSelectMethod_button_Back">
<div class="x-inner-el" id="ext-element-2445">
<div class="x-body-el" id="ext-element-2444">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-2447" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-2446">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2443" aria-labelledby="ext-element-2446"
data-componentid="ForgotPasswordSelectMethod_button_Back"></button>
</div>
<div data-componentid="ForgotPasswordSelectMethod_spacer_6" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1233" id="ForgotPasswordSelectMethod_spacer_6" style="flex: 1 1 0%;"></div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="FormEnterCode"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="1299" id="FormEnterCode">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-2612">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-2567">
<div data-componentid="ValidationSummary_14" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="1300" id="ValidationSummary_14">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-2568"></div>
<div id="ext-element-2569"></div>
</div>
<div data-componentid="FormEnterCode_container" class="x-container x-component x-layout-auto-item" data-xid="1301" id="FormEnterCode_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2570"></div>
</div>
<div data-componentid="FormEnterCode_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1302" id="FormEnterCode_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2571">
<div data-componentid="FormEnterCode_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1303" id="FormEnterCode_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="FormEnterCode_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="1304" id="FormEnterCode_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2572">
<div class="x-innerhtml" id="ext-element-2573"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="FormEnterCode_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1305" id="FormEnterCode_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="FormEnterCode_container_3" class="x-container x-component x-layout-auto-item" data-xid="1306" id="FormEnterCode_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2574"></div>
</div>
<div data-componentid="FormEnterCode_container_4" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1307" id="FormEnterCode_container_4">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2575">
<div data-componentid="FormEnterCode_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1308" id="FormEnterCode_spacer_2" style="flex: 1 1 0%;"></div>
<div data-componentid="FormEnterCode_instamedLabelHeading1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="1309"
id="FormEnterCode_instamedLabelHeading1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-2576">Enter Code</h1>
</div>
<div data-componentid="FormEnterCode_spacer_3" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1310" id="FormEnterCode_spacer_3" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="FormEnterCode_container_5" class="x-container x-component x-layout-auto-item" data-xid="1311" id="FormEnterCode_container_5" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2577"></div>
</div>
<div data-componentid="FormEnterCode_container_6" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1312" id="FormEnterCode_container_6">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2578">
<div data-componentid="FormEnterCode_spacer_4" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1313" id="FormEnterCode_spacer_4" style="flex: 1 1 0%;"></div>
<div data-componentid="FormEnterCode_EnterCode" class="x-component x-label im-font-500 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item"
data-xid="1314" id="FormEnterCode_EnterCode">
<div class="x-innerhtml" id="ext-element-2579">We emailed a password reset code to <span class="im-wrap-email">{0}</span>.<br>For security reasons, the code will expire in 15 minutes.</div>
</div>
<div data-componentid="FormEnterCode_spacer_5" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1315" id="FormEnterCode_spacer_5" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="FormEnterCode_container_7" class="x-container x-component x-layout-auto-item" data-xid="1316" id="FormEnterCode_container_7" style="min-height: 20px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2580"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="FormEnterCode_PasswordResetCode" data-xid="1317" id="FormEnterCode_PasswordResetCode" style="min-width: 256px;"><label class="x-label-el" for="ext-element-2581" id="ext-element-2583"><span class="x-label-text-el"
id="ext-element-2584">Password Reset Code</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2582">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2585"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="number" id="ext-element-2581" maxlength="6" autocorrect="off"
aria-labelledby="ext-element-2584" pattern="[0-9]*" aria-required="true" autocomplete="off" name="PasswordResetCode" aria-readonly="false" data-componentid="FormEnterCode_PasswordResetCode" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2586"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2587"></div>
</div>
</div>
</div>
<div data-componentid="FormEnterCode_container_8" class="x-container x-component x-layout-auto-item" data-xid="1318" id="FormEnterCode_container_8" style="min-height: 12px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2588"></div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="FormEnterCode_PasswordResetCounter" data-xid="1319" id="FormEnterCode_PasswordResetCounter"><label class="x-label-el" for="ext-element-2589" id="ext-element-2591"><span class="x-label-text-el"
id="ext-element-2592">PasswordResetCounter</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2590"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2589" aria-labelledby="ext-element-2592" value="0" aria-required="false"
name="PasswordResetCounter" aria-readonly="false" data-componentid="FormEnterCode_PasswordResetCounter" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2593"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="FormEnterCode_ResetCodeCounter" data-xid="1320" id="FormEnterCode_ResetCodeCounter"><label class="x-label-el" for="ext-element-2594" id="ext-element-2596"><span class="x-label-text-el"
id="ext-element-2597">ResetCodeCounter</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2595"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2594" aria-labelledby="ext-element-2597" value="0" aria-required="false"
name="ResetCodeCounter" aria-readonly="false" data-componentid="FormEnterCode_ResetCodeCounter" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2598"></div>
</div>
</div>
</div>
<div data-componentid="FormEnterCode_container_9" class="x-container x-component x-layout-auto-item" data-xid="1321" id="FormEnterCode_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-2599">
<div onclick="return Ext.doEv(this, event);" data-componentid="FormEnterCode_button_Confirm"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="1322" id="FormEnterCode_button_Confirm">
<div class="x-inner-el" id="ext-element-2602">
<div class="x-body-el" id="ext-element-2601">
<div class="x-icon-el x-font-icon" id="ext-element-2604"></div>
<div class="x-text-el" id="ext-element-2603">Confirm</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2600" aria-labelledby="ext-element-2603"
data-componentid="FormEnterCode_button_Confirm"></button>
</div>
</div>
</div>
<div data-componentid="FormEnterCode_container_10" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="1323" id="FormEnterCode_container_10">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-2605">
<div onclick="return Ext.doEv(this, event);" data-componentid="FormEnterCode_button_Back"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="1324"
id="FormEnterCode_button_Back">
<div class="x-inner-el" id="ext-element-2608">
<div class="x-body-el" id="ext-element-2607">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-2610" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-2609">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2606" aria-labelledby="ext-element-2609"
data-componentid="FormEnterCode_button_Back"></button>
</div>
<div data-componentid="FormEnterCode_spacer_6" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1325" id="FormEnterCode_spacer_6" style="flex: 1 1 0%;"></div>
<div data-componentid="FormEnterCode_ResendCode" class="x-component x-label top-pad-8 light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item" data-xid="1326"
id="FormEnterCode_ResendCode">
<div class="x-innerhtml" id="ext-element-2611"><a href="javascript:PerformAction({}, ResetPasswordController.resendPasswordResetCode);" class="im-link-underline-none im-default-link">Resend Code</a></div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="CreateNewPassword"
class="x-formpanel x-panel x-container x-component x-noborder-trbl col-large-offSet-3 col-medium-offSet-3 col-small-offSet-1 smallTenColumn xsmallTwelveColumn mediumSixColumn largeSixColumn im-form-margin-rule x-header-position-top x-managed-borders x-layout-auto-item"
data-xid="1392" id="CreateNewPassword">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el" id="ext-element-2837">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-noborder-trbl" style="border-width: 0px;" id="ext-element-2731">
<div data-componentid="ValidationSummary_15" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="1393" id="ValidationSummary_15">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-2732"></div>
<div id="ext-element-2733"></div>
</div>
<div data-componentid="CreateNewPassword_container" class="x-container x-component x-layout-auto-item" data-xid="1394" id="CreateNewPassword_container" style="min-height: 10px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2734"></div>
</div>
<div data-componentid="CreateNewPassword_container_1" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1395" id="CreateNewPassword_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2735">
<div data-componentid="CreateNewPassword_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1396" id="CreateNewPassword_spacer" style="flex: 1 1 0%;"></div>
<div data-componentid="CreateNewPassword_container_2" class="x-container x-component x-layout-box-item x-layout-hbox-item" data-xid="1397" id="CreateNewPassword_container_2">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2736">
<div class="x-innerhtml" id="ext-element-2737"><img src="https://cdn.instamed.com/V_2024_May/Content/Images/General/pplogo_usbank-55px.png" alt="U.S. Bank logo" style="height: 48px"></div>
</div>
</div>
<div data-componentid="CreateNewPassword_spacer_1" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1398" id="CreateNewPassword_spacer_1" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_3" class="x-container x-component x-layout-auto-item" data-xid="1399" id="CreateNewPassword_container_3" style="min-height: 36px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2738"></div>
</div>
<div data-componentid="CreateNewPassword_container_4" class="x-container x-component x-layout-auto-item" data-xid="1400" id="CreateNewPassword_container_4" style="min-height: 8px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2739"></div>
</div>
<div data-componentid="CreateNewPassword_container_5" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1401" id="CreateNewPassword_container_5">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2740">
<div data-componentid="CreateNewPassword_spacer_2" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1402" id="CreateNewPassword_spacer_2" style="flex: 1 1 0%;"></div>
<div data-componentid="CreateNewPassword_instamedLabelHeading1" class="x-component x-label im-font-500 headline-font x-label-headline-font x-component-headline-font x-layout-box-item x-layout-hbox-item" data-xid="1403"
id="CreateNewPassword_instamedLabelHeading1">
<h1 class="x-innerhtml instamed-label-heading1" id="ext-element-2741">Create A New Password</h1>
</div>
<div data-componentid="CreateNewPassword_spacer_3" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1404" id="CreateNewPassword_spacer_3" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_6" class="x-container x-component x-layout-auto-item" data-xid="1405" id="CreateNewPassword_container_6" style="min-height: 8px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2742"></div>
</div>
<div data-componentid="CreateNewPassword_container_7" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1406" id="CreateNewPassword_container_7">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2743">
<div data-componentid="CreateNewPassword_spacer_4" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1407" id="CreateNewPassword_spacer_4" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="CreateNewPassword_Email"
class="x-component x-button margin-bottom-10 im-default-cursor Grey-Outlined-Rounded noprint x-icon-align-left x-arrow-align-right x-button-Grey-Outlined-Rounded x-component-Grey-Outlined-Rounded x-layout-box-item x-layout-hbox-item"
data-xid="1408" id="CreateNewPassword_Email">
<div class="x-inner-el" id="ext-element-2746">
<div class="x-body-el" id="ext-element-2745">
<div class="x-icon-el x-font-icon" id="ext-element-2747"></div>
<div class="x-text-el"></div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2744" data-componentid="CreateNewPassword_Email"></button>
</div>
<div data-componentid="CreateNewPassword_spacer_5" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1409" id="CreateNewPassword_spacer_5" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="CreateNewPassword_ChallengeQuestionContainer" class="x-container x-component x-layout-auto-item" data-xid="1410" id="CreateNewPassword_ChallengeQuestionContainer">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2748">
<div data-componentid="CreateNewPassword_container_8" class="x-container x-component x-layout-auto-item" data-xid="1411" id="CreateNewPassword_container_8" style="min-height: 16px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2749"></div>
</div>
<div data-componentid="CreateNewPassword_container_9" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1412" id="CreateNewPassword_container_9">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2750">
<div data-componentid="CreateNewPassword_spacer_6" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1413" id="CreateNewPassword_spacer_6" style="flex: 1 1 0%;"></div>
<div data-componentid="CreateNewPassword_label" class="x-component x-label im-font-500 subheading-secondary x-label-subheading-secondary x-component-subheading-secondary x-layout-box-item x-layout-hbox-item" data-xid="1414"
id="CreateNewPassword_label">
<div class="x-innerhtml" id="ext-element-2751">Challenge Question</div>
</div>
<div data-componentid="CreateNewPassword_spacer_7" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1415" id="CreateNewPassword_spacer_7" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_10" class="x-container x-component x-layout-auto-item" data-xid="1416" id="CreateNewPassword_container_10" style="min-height: 8px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2752"></div>
</div>
<div data-componentid="CreateNewPassword_container_11" class="x-container x-component x-center-helper x-layout-auto-item" data-xid="1417" id="CreateNewPassword_container_11">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-center x-layout-hbox x-horizontal x-align-stretch" id="ext-element-2753">
<div data-componentid="CreateNewPassword_spacer_8" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1418" id="CreateNewPassword_spacer_8" style="flex: 1 1 0%;"></div>
<div data-componentid="CreateNewPassword_ChallengeQuestion" class="x-component x-label light-subheading-secondary x-label-light-subheading-secondary x-component-light-subheading-secondary x-layout-box-item x-layout-hbox-item"
data-xid="1419" id="CreateNewPassword_ChallengeQuestion"></div>
<div data-componentid="CreateNewPassword_spacer_9" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1420" id="CreateNewPassword_spacer_9" style="flex: 1 1 0%;"></div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_12" class="x-container x-component x-layout-auto-item" data-xid="1421" id="CreateNewPassword_container_12" style="min-height: 12px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2754"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="CreateNewPassword_SecretAnswerPatientID" data-xid="1422" id="CreateNewPassword_SecretAnswerPatientID"><label class="x-label-el" for="ext-element-2755" id="ext-element-2757"><span class="x-label-text-el"
id="ext-element-2758">Secret Answer</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2756">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2759"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-2755" maxlength="10" autocorrect="off"
aria-labelledby="ext-element-2758" placeholder="As it appears on your statement" aria-required="false" autocomplete="off" name="SecretAnswerPatientID" aria-readonly="false" data-componentid="CreateNewPassword_SecretAnswerPatientID"
aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2760"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2761">This is found on your bill. It may also be called Statement ID, Patient ID, Guarantor ID or Encounter ID.</div>
</div>
</div>
</div>
<div
class="x-no-min-content x-datepickerfield x-pickerfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-size-monitored x-paint-monitored x-layout-auto-item"
data-componentid="CreateNewPassword_SecretAnswerDateOfBirth" data-xid="1423" id="CreateNewPassword_SecretAnswerDateOfBirth"><label class="x-label-el" for="ext-element-2762" id="ext-element-2764"><span class="x-label-text-el"
id="ext-element-2765">Secret Answer</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2763">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2766"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-2762" aria-labelledby="ext-element-2765" placeholder="MM/DD/YYYY"
aria-required="false" autocomplete="off" name="SecretAnswerDateOfBirth" aria-readonly="false" data-componentid="CreateNewPassword_SecretAnswerDateOfBirth" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2767">
<div data-componentid="ext-datetrigger-3" class="x-datetrigger x-trigger x-interactive" data-xid="1424" id="ext-datetrigger-3">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2768"></div>
</div>
</div>
<div class="x-size-monitors scroll">
<div class="expand"></div>
<div class="shrink"></div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div class="x-no-min-content x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-layout-auto-item"
data-componentid="CreateNewPassword_SecretAnswer" data-xid="1425" id="CreateNewPassword_SecretAnswer"><label class="x-label-el" for="ext-element-2769" id="ext-element-2771"><span class="x-label-text-el" id="ext-element-2772">Secret
Answer</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2770">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2773"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="text" id="ext-element-2769" maxlength="10" autocorrect="off"
aria-labelledby="ext-element-2772" aria-required="false" autocomplete="off" name="SecretAnswer" aria-readonly="false" data-componentid="CreateNewPassword_SecretAnswer" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2774"></div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2775"></div>
</div>
</div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="CreateNewPassword_SecretAnswerID" data-xid="1426" id="CreateNewPassword_SecretAnswerID"><label class="x-label-el" for="ext-element-2776" id="ext-element-2778"><span class="x-label-text-el"
id="ext-element-2779">SecretAnswerID</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2777"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2776" aria-labelledby="ext-element-2779" aria-required="false" name="SecretAnswerID"
aria-readonly="false" data-componentid="CreateNewPassword_SecretAnswerID" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2780"></div>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_im_account_summary_legend_total_balance_divi" class="x-container x-component im-account-summary-legend-total-balance-divider x-layout-auto-item" data-xid="1427"
id="CreateNewPassword_im_account_summary_legend_total_balance_divi">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2781"></div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="CreateNewPassword_TransactionSuccess" data-xid="1428" id="CreateNewPassword_TransactionSuccess"><label class="x-label-el" for="ext-element-2782" id="ext-element-2784"><span class="x-label-text-el"
id="ext-element-2785">TransactionSuccess</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2783"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2782" aria-labelledby="ext-element-2785" aria-required="false"
name="TransactionSuccess" aria-readonly="false" data-componentid="CreateNewPassword_TransactionSuccess" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2786"></div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="CreateNewPassword_Password" data-xid="1429" id="CreateNewPassword_Password"><label class="x-label-el" for="ext-element-2787" id="ext-element-2789"><span class="x-label-text-el" id="ext-element-2790">Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2788">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2791"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-2787" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-2790" placeholder="Must be different from 5 previous passwords" aria-required="true" autocomplete="on" name="Password" autocapitalize="off" aria-readonly="false"
data-componentid="CreateNewPassword_Password" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2792">
<div data-componentid="ext-revealtrigger-9" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="1430" id="ext-revealtrigger-9">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2793"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="CreateNewPassword_PasswordVisualizerChecklist" class="x-container x-component x-hidden x-hidden-display x-layout-auto-item" data-xid="1431" id="CreateNewPassword_PasswordVisualizerChecklist">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2794">
<div data-componentid="CreateNewPassword_label_1" class="x-component x-label x-layout-auto-item" data-xid="1432" id="CreateNewPassword_label_1">
<div class="x-innerhtml" id="ext-element-2795">Password must:</div>
</div>
<div data-componentid="CreateNewPassword_container_13" class="x-container x-component x-layout-auto-item" data-xid="1433" id="CreateNewPassword_container_13">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-2796">
<div data-componentid="CreateNewPassword_8charsIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="1434" id="CreateNewPassword_8charsIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-2797"></div>
</div>
<div data-componentid="CreateNewPassword_8charsLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="1435" id="CreateNewPassword_8charsLabel">
<div class="x-innerhtml" id="ext-element-2798">Contain at least 8 characters</div>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_CharacterTypes" class="x-component x-label RedLabel x-layout-auto-item" data-xid="1436" id="CreateNewPassword_CharacterTypes">
<div class="x-innerhtml" id="ext-element-2799">Contain at least 3 of the following 4 characters:</div>
</div>
<div data-componentid="CreateNewPassword_container_14" class="x-container x-component x-layout-auto-item" data-xid="1437" id="CreateNewPassword_container_14">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-2800">
<div data-componentid="CreateNewPassword_lowerCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="1438" id="CreateNewPassword_lowerCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-2801"></div>
</div>
<div data-componentid="CreateNewPassword_lowerCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="1439" id="CreateNewPassword_lowerCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-2802">1 lowercase letter</div>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_15" class="x-container x-component x-layout-auto-item" data-xid="1440" id="CreateNewPassword_container_15">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-2803">
<div data-componentid="CreateNewPassword_upperCaseLetterIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="1441" id="CreateNewPassword_upperCaseLetterIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-2804"></div>
</div>
<div data-componentid="CreateNewPassword_upperCaseLetterLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="1442" id="CreateNewPassword_upperCaseLetterLabel">
<div class="x-innerhtml" id="ext-element-2805">1 uppercase letter</div>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_16" class="x-container x-component x-layout-auto-item" data-xid="1443" id="CreateNewPassword_container_16">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-2806">
<div data-componentid="CreateNewPassword_oneNumberIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="1444" id="CreateNewPassword_oneNumberIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-2807"></div>
</div>
<div data-componentid="CreateNewPassword_oneNumberLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="1445" id="CreateNewPassword_oneNumberLabel">
<div class="x-innerhtml" id="ext-element-2808">1 number</div>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_17" class="x-container x-component x-layout-auto-item" data-xid="1446" id="CreateNewPassword_container_17">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-float direction-left" id="ext-element-2809">
<div data-componentid="CreateNewPassword_OneSymbolIcon" class="x-tool x-component RedLabel SmallIcon x-layout-float-item" data-xid="1447" id="CreateNewPassword_OneSymbolIcon">
<div class="x-icon-el x-font-icon x-ma ma-clear" id="ext-element-2810"></div>
</div>
<div data-componentid="CreateNewPassword_OneSymbolLabel" class="x-component x-label RedLabel x-layout-float-item" data-xid="1448" id="CreateNewPassword_OneSymbolLabel">
<div class="x-innerhtml" id="ext-element-2811">1 special character</div>
</div>
</div>
</div>
</div>
</div>
<div
class="x-no-min-content x-passwordfield x-textfield x-field x-component x-body-align-stretch x-label-text-align-left x-labeled x-required x-label-align-placeholder x-label-align-vertical x-error-target-under x-empty x-paint-monitored x-layout-auto-item"
data-componentid="CreateNewPassword_ConfirmNewPassword" data-xid="1449" id="CreateNewPassword_ConfirmNewPassword"><label class="x-label-el" for="ext-element-2812" id="ext-element-2814"><span class="x-label-text-el"
id="ext-element-2815">Confirm Password</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2813">
<div class="x-input-wrap-el">
<div class="x-before-input-el" id="ext-element-2816"></div><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="password" id="ext-element-2812" maxlength="30" autocorrect="off"
aria-labelledby="ext-element-2815" aria-required="true" autocomplete="on" name="ConfirmNewPassword" autocapitalize="off" aria-readonly="false" data-componentid="CreateNewPassword_ConfirmNewPassword" aria-invalid="false">
<div class="x-after-input-el" id="ext-element-2817">
<div data-componentid="ext-revealtrigger-10" class="x-revealtrigger x-trigger x-hidden-display x-interactive" data-xid="1450" id="ext-revealtrigger-10">
<div class="x-icon-el x-font-icon"></div>
</div>
</div>
</div>
<div class="x-underline-el"></div>
</div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2818"></div>
</div>
</div>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div data-componentid="CreateNewPassword_container_18" class="x-container x-component x-layout-auto-item" data-xid="1451" id="CreateNewPassword_container_18" style="min-height: 11px;">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2819"></div>
</div>
<div class="x-no-min-content x-hiddenfield x-field x-component x-body-align-start x-label-align-left x-label-align-horizontal x-label-text-align-left x-labeled x-error-target-under x-layout-auto-item"
data-componentid="CreateNewPassword_IsPaymentFlow" data-xid="1452" id="CreateNewPassword_IsPaymentFlow"><label class="x-label-el" for="ext-element-2820" id="ext-element-2822"><span class="x-label-text-el"
id="ext-element-2823">IsPaymentFlow</span></label>
<div class="x-body-wrap-el">
<div class="x-body-el" id="ext-element-2821"><input tabindex="0" oninput="return Ext.doEv(this, event);" class="x-input-el" type="hidden" id="ext-element-2820" aria-labelledby="ext-element-2823" value="false" aria-required="false"
name="IsPaymentFlow" aria-readonly="false" data-componentid="CreateNewPassword_IsPaymentFlow" aria-invalid="false"></div>
<div class="x-error-el">
<div class="x-error-icon-el x-font-icon"></div>
<div class="x-help-message-el" id="ext-element-2824"></div>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_19" class="x-container x-component x-layout-auto-item" data-xid="1453" id="CreateNewPassword_container_19">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-layout-vbox x-vertical x-align-stretch x-pack-start" id="ext-element-2825">
<div onclick="return Ext.doEv(this, event);" data-componentid="CreateNewPassword_button_Save"
class="x-component x-button x-has-text im-full-width-button action noprint x-icon-align-left x-arrow-align-right x-button-action x-component-action x-layout-box-item x-layout-vbox-item" data-xid="1454" id="CreateNewPassword_button_Save">
<div class="x-inner-el" id="ext-element-2828">
<div class="x-body-el" id="ext-element-2827">
<div class="x-icon-el x-font-icon" id="ext-element-2830"></div>
<div class="x-text-el" id="ext-element-2829">Save</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2826" aria-labelledby="ext-element-2829"
data-componentid="CreateNewPassword_button_Save"></button>
</div>
</div>
</div>
<div data-componentid="CreateNewPassword_container_20" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="1455" id="CreateNewPassword_container_20">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-2831">
<div onclick="return Ext.doEv(this, event);" data-componentid="CreateNewPassword_button_Back"
class="x-component x-button x-has-text x-has-icon Initial-Caps noprint x-icon-align-left x-arrow-align-right x-button-Initial-Caps x-component-Initial-Caps x-layout-box-item x-layout-hbox-item" data-xid="1456"
id="CreateNewPassword_button_Back">
<div class="x-inner-el" id="ext-element-2834">
<div class="x-body-el" id="ext-element-2833">
<div class="x-icon-el x-font-icon x-ma ma-arrow-back" id="ext-element-2836" aria-hidden="true"></div>
<div class="x-text-el" id="ext-element-2835">Back</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2832" aria-labelledby="ext-element-2835"
data-componentid="CreateNewPassword_button_Back"></button>
</div>
<div data-componentid="CreateNewPassword_spacer_10" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1457" id="CreateNewPassword_spacer_10" style="flex: 1 1 0%;"></div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form><form novalidate="novalidate" data-componentid="MyFormPanel"
class="x-formpanel x-panel x-container x-component x-noborder-trbl flat x-header-position-top x-formpanel-flat x-panel-flat x-container-flat x-component-flat x-managed-borders x-layout-auto-item" data-xid="1501" id="MyFormPanel">
<div class="x-body-wrap-el x-formpanel-body-wrap-el x-panel-body-wrap-el x-container-body-wrap-el x-component-body-wrap-el x-formpanel-flat-body-wrap-el x-panel-flat-body-wrap-el x-container-flat-body-wrap-el x-component-flat-body-wrap-el"
id="ext-element-2925">
<div class="x-body-el x-formpanel-body-el x-panel-body-el x-container-body-el x-component-body-el x-layout-auto x-formpanel-flat-body-el x-panel-flat-body-el x-container-flat-body-el x-component-flat-body-el x-noborder-trbl"
style="border-width: 0px;" id="ext-element-2909">
<div data-componentid="ValidationSummary_16" class="x-container x-component x-hidden x-hidden-display ErrorBox x-container-ErrorBox x-component-ErrorBox x-layout-auto-item" data-xid="1502" id="ValidationSummary_16">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto x-container-ErrorBox-body-el x-component-ErrorBox-body-el" id="ext-element-2910"></div>
<div id="ext-element-2911"></div>
</div>
<div data-componentid="MyFormPanel_IdleTimerNotification" class="x-component x-label x-layout-auto-item" data-xid="1503" id="MyFormPanel_IdleTimerNotification">
<div class="x-innerhtml" id="ext-element-2912"><span id="header" role="alert" aria-live="assertive">You have been idle for <strong><span id="main-minutes">12 minutes</span></strong></span>. If you do not select Continue or you make no
selection in <strong> <span id="minutes">3 minutes and </span><span id="seconds">0 seconds</span></strong>, your session will be refreshed and you may lose any unprocessed information.</div>
</div>
<div data-componentid="MyFormPanel_container" class="x-container x-component x-layout-auto-item" data-xid="1504" id="MyFormPanel_container">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-auto" id="ext-element-2913">
<div data-componentid="MyFormPanel_container_1" class="x-container x-component buttonContainer x-layout-auto-item" data-xid="1505" id="MyFormPanel_container_1">
<div class="x-body-el x-container-body-el x-component-body-el x-layout-box x-pack-start x-align-end x-layout-hbox x-horizontal" id="ext-element-2914">
<div data-componentid="MyFormPanel_spacer" class="x-component x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1506" id="MyFormPanel_spacer" style="flex: 1 1 0%;"></div>
<div onclick="return Ext.doEv(this, event);" data-componentid="MyFormPanel_button_Logout"
class="x-component x-button x-has-text x-hidden x-hidden-display secondary noprint x-icon-align-left x-arrow-align-right x-button-secondary x-component-secondary x-paint-monitored x-layout-box-item x-layout-hbox-item x-flexed"
data-xid="1507" id="MyFormPanel_button_Logout" style="flex: 1 1 0%;">
<div class="x-inner-el" id="ext-element-2917">
<div class="x-body-el" id="ext-element-2916">
<div class="x-icon-el x-font-icon" id="ext-element-2919"></div>
<div class="x-text-el" id="ext-element-2918">Logout</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2915" aria-labelledby="ext-element-2918"
data-componentid="MyFormPanel_button_Logout"></button>
<div class="x-paint-monitor cssanimation"></div>
</div>
<div onclick="return Ext.doEv(this, event);" data-componentid="MyFormPanel_button_Continue"
class="x-component x-button x-has-text secondary noprint x-icon-align-left x-arrow-align-right x-button-secondary x-component-secondary x-paint-monitored x-layout-box-item x-layout-hbox-item x-flexed" data-xid="1508"
id="MyFormPanel_button_Continue" aria-label="Continue" style="flex: 1 1 0%;">
<div class="x-inner-el" id="ext-element-2922">
<div class="x-body-el" id="ext-element-2921">
<div class="x-icon-el x-font-icon" id="ext-element-2924"></div>
<div class="x-text-el" id="ext-element-2923">Continue</div>
</div>
<div class="x-arrow-el x-font-icon"></div>
</div>
<div class="x-badge-el"></div><button onfocus="return Ext.doEv(this, event);" onblur="return Ext.doEv(this, event);" class="x-button-el" type="button" id="ext-element-2920" aria-labelledby="ext-element-2923"
data-componentid="MyFormPanel_button_Continue"></button>
<div class="x-paint-monitor cssanimation"></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div><input type="submit" class="x-hidden-submit">
</form>Text Content
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FORGOT PASSWORD
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remember the email used, please contact (866) 467-8263.
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First Name
Last Name
Email
Password
Password must:
Contain at least 8 characters
Contain at least 3 of the following 4 characters:
1 lowercase letter
1 uppercase letter
1 number
1 special character
Confirm Password
PushNotificationToken
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SET UP SECURITY QUESTIONS
Question 1
Secret Answer for Question 1
Question 2
Secret Answer for Question 2
Question 3
Secret Answer for Question 3
UIAction
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FORGOT PASSWORD
Please enter the email address associated with your account. If you do not
remember the email used, please contact (866) 467-8263.
Email
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PLEASE LOG IN OR SIGN UP
DualLoginSignUpSelectedType
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Email
Password
First Name
Last Name
Email
Password
Password must:
Contain at least 8 characters
Contain at least 3 of the following 4 characters:
1 lowercase letter
1 uppercase letter
1 number
1 special character
Confirm Password
Forgot Password?
Log In
Skip To Receipt
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TWO-STEP VERIFICATION REQUIRED
You are enrolled in two-step verification when accessing your account from a new
device or browser. We have texted your phone number on file
Verification Code
Remember this device in the future
Counter
LoginCounter
Flow
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KEEP YOUR ACCOUNT SAFE AND UPDATED
To increase your security, please add and verify your mobile phone number. You
can use this to reset passwords, enable two-step verification and enroll in
payment alerts via text message.
To increase your security, please add and verify your mobile phone number. You
can use this to reset passwords and enable two-step verification.
Mobile Phone Number
Enable Two-Step Verification
By enrolling in two-step verification and/or text alerts, you agree to all
InstaMed Communications Terms and Conditions. InstaMed will only use this number
for account security and payment alerts. Message and data rates may apply.
EnrollInTextAlerts
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FORGOT PASSWORD
Please select a method to reset your password.
VerificationCodeMethod
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ENTER CODE
We emailed a password reset code to {0}.
For security reasons, the code will expire in 15 minutes.
Password Reset Code
PasswordResetCounter
ResetCodeCounter
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CREATE A NEW PASSWORD
Challenge Question
Secret Answer
This is found on your bill. It may also be called Statement ID, Patient ID,
Guarantor ID or Encounter ID.
Secret Answer
Secret Answer
SecretAnswerID
TransactionSuccess
Password
Password must:
Contain at least 8 characters
Contain at least 3 of the following 4 characters:
1 lowercase letter
1 uppercase letter
1 number
1 special character
Confirm Password
IsPaymentFlow
Save
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INACTIVITY ALERT
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selection in 3 minutes and 0 seconds, your session will be refreshed and you may
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