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POST /recalls/aZlhn4Vnzs7lNE_0bNn-tA

<form action="/recalls/aZlhn4Vnzs7lNE_0bNn-tA" accept-charset="UTF-8" method="post">
  <div class="field">
    <label>Your Last Name</label>
    <input id="last_name" tabindex="1" type="text" autocomplete="off" autocorrect="off" name="last_name" placeholder="Last Name">
  </div>
  <div class="field">
    <label> Your Date of Birth</label>
    <div class="dob">
      <div class="cell">
        <input id="dob_day" name="date_of_birth[day]" tabindex="2" class="auto-advance" type="number" min="1" max="31" inputmode="numeric" pattern="[0-9]*" placeholder="DD" autocomplete="off" autocorrect="off">
      </div>
      <div class="cell">
        <input id="dob_month" name="date_of_birth[month]" tabindex="3" class="auto-advance" type="number" min="1" max="12" inputmode="numeric" pattern="[0-9]*" placeholder="MM" autocomplete="off" autocorrect="off">
      </div>
      <div class="cell">
        <input id="dob_year" name="date_of_birth[year]" tabindex="4" type="number" min="0" inputmode="numeric" pattern="[0-9]*" placeholder="YYYY" autocomplete="off" autocorrect="off">
      </div>
    </div>
  </div>
  <script type="text/javascript">
    // Focus next field when the user hits the 'Go' button on iOS keyboard.
    var nameInput = document.getElementById("last_name");
    nameInput.addEventListener("keypress", function(e) {
      var keycode = (event.keyCode ? event.keyCode : event.which);
      if (keycode == '13') {
        document.getElementById("dob_day").focus();
        e.preventDefault();
      }
    });
    // Advance DOB fields automatically after two digits
    var autoAdvanceInputs = document.getElementsByClassName("auto-advance");
    for (var i = 0; i < autoAdvanceInputs.length; i++) {
      var input = autoAdvanceInputs[i];
      input.addEventListener("input", function(e) {
        if (event.target.value.length == 2) {
          var tabIndex = event.target.tabIndex;
          document.getElementsByTagName('input')[tabIndex].focus();
        }
      });
    }
  </script>
  <button type="submit" class="button">Verify</button>
</form>

Text Content

https://d3sjaxzllw9rho.cloudfront.net/clinic_images/clinic_profiles/10984/thumb_49a1acdf2c1654c898a9b6df7e4da5ba.jpg


COBURG FAMILY MEDICAL CENTRE

03 9354 4042

Please verify your identity to read your health message.

Please fill out all fields.

Your Last Name
Your Date of Birth

Verify


ABOUT THIS RECALL SERVICE

At Coburg Family Medical Centre we use a secure electronic 'recall & reminder
service' so we may notify you of upcoming due appointments and procedures. This
system also allows you to easily book your appointment by phone or online where
applicable.


UNABLE TO VERIFY?

This could mean your patient record at Coburg Family Medical Centre doesn't
match what you have entered. Please ensure you are typing your last name and
date of birth as supplied at the time of registration. Alternatively contact us
on 03 9354 4042 to book your appointment directly.


DO YOU WISH TO OPT-OUT?

If you no longer wish to receive recall SMSs from Coburg Family Medical Centre,
please click this link.