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pay.balancecollect.com Open in urlscan Pro
54.92.139.53  Public Scan

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URL: https://pay.balancecollect.com/m/highlandsmiles
Submission: On September 23 via manual from US — Scanned from DE

Form analysis 2 forms found in the DOM

POST 

<form class="col-12" id="payment-form" method="post">
  <div class="white-background">
    <div class="col-12 text-right required-field-span"> Erforderliches Feld * </div>
    <select id="merchant_account" name="merchant_account" style="display:none;">
      <option display_name="Highland Smiles" value="36503"> Highland Smiles </option>
    </select>
    <div class="col-12" id="payment-div">
      <span class="page-heading">Zusätzliche Informationen</span>
    </div>
    <div class="form-row">
      <div class="col">
        <input type="hidden" id="Patient_First_and_Last_Name" value="Patient First and Last Name">
        <label for="PATIENT_FIRST_AND_LAST_NAME" class="form-label">Patient First and Last Name</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" name="custom_field" data-required="0" data="PATIENT_FIRST_AND_LAST_NAME" display_name="Patient First and Last Name" required_field="0" id="PATIENT_FIRST_AND_LAST_NAME"
            placeholder="">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper">
              <i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i>
            </span>
          </span>
        </div>
        <div class="validation-error" id="PATIENT_FIRST_AND_LAST_NAME-error"></div>
      </div>
    </div>
    <div class="col-12" id="payment-div">
      <span class="page-heading">Zahlungsinformation</span>
    </div>
    <div class="form-row">
      <div class="col-md-6">
        <label for="ccNumber" class="form-label">Kreditkartennummer *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0 " name="ccNumber" id="ccNumber" maxlength="16" autofocus="" placeholder="" data-required="1">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="ccNumber-error"></div>
      </div>
      <div class="col-6 col-md-3">
        <label for="expiration" class="form-label">gültig bis *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0 " name="expiration" id="expiration" maxlength="5" placeholder="MM/YY" data-required="1">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="expiration-error"></div>
      </div>
      <div class="col-6 col-md-3">
        <label for="cvv" class="form-label">Kartenprüfnummer (CVV) *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0 " name="cvv" id="cvv" maxlength="4" placeholder="" data-required="1">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="cvv-error"></div>
      </div>
    </div>
    <div class="form-row">
      <div class="col-md-6">
        <label for="first_name" class="form-label">Vorname *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" name="first_name" id="first_name" placeholder="" data-required="1">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="first_name-error"></div>
      </div>
      <div class="col-md-6">
        <label for="last_name" class="form-label">Nachname *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" name="last_name" id="last_name" placeholder="" data-required="1">
          <span class="input-group-append bg-white border-left-0 ">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="last_name-error"></div>
      </div>
    </div>
    <select id="country" name="country" style="display:none;">
      <option display_name="USA" value="US"> USA </option>
    </select>
    <div class="form-row">
      <div class="col">
        <label for="address_line_1" class="form-label">Straße</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" name="address_line_1" id="address_line_1" placeholder="" data-required="">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="address_line_1-error"></div>
      </div>
    </div>
    <div class="form-row">
      <div class="col-md-6">
        <label for="city" class="form-label">Stadt</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" name="city" id="city" placeholder="" data-required="">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="city-error"></div>
      </div>
      <div class="col-6 col-md-3">
        <label for="state" class="form-label">Bundesland</label>
        <select id="state" class="state-box select select-arrow-down form-control billing-elements" name="state" data-required="" placeholder="State">
          <option value="">Select</option>
          <option value="AL"> AL </option>
          <option value="AK"> AK </option>
          <option value="AZ"> AZ </option>
          <option value="AR"> AR </option>
          <option value="CA"> CA </option>
          <option value="CO"> CO </option>
          <option value="CT"> CT </option>
          <option value="DC"> DC </option>
          <option value="DE"> DE </option>
          <option value="FL"> FL </option>
          <option value="GA"> GA </option>
          <option value="HI"> HI </option>
          <option value="ID"> ID </option>
          <option value="IL"> IL </option>
          <option value="IN"> IN </option>
          <option value="IA"> IA </option>
          <option value="KS"> KS </option>
          <option value="KY"> KY </option>
          <option value="LA"> LA </option>
          <option value="ME"> ME </option>
          <option value="MD"> MD </option>
          <option value="MA"> MA </option>
          <option value="MI"> MI </option>
          <option value="MN"> MN </option>
          <option value="MS"> MS </option>
          <option value="MO"> MO </option>
          <option value="MT"> MT </option>
          <option value="NE"> NE </option>
          <option value="NV"> NV </option>
          <option value="NH"> NH </option>
          <option value="NJ"> NJ </option>
          <option value="NM"> NM </option>
          <option value="NY"> NY </option>
          <option value="NC"> NC </option>
          <option value="ND"> ND </option>
          <option value="OH"> OH </option>
          <option value="OK"> OK </option>
          <option value="OR"> OR </option>
          <option value="PA"> PA </option>
          <option value="RI"> RI </option>
          <option value="SC"> SC </option>
          <option value="SD"> SD </option>
          <option value="TN"> TN </option>
          <option value="TX"> TX </option>
          <option value="UT"> UT </option>
          <option value="VT"> VT </option>
          <option value="VA"> VA </option>
          <option value="WA"> WA </option>
          <option value="WV"> WV </option>
          <option value="WI"> WI </option>
          <option value="WY"> WY </option>
        </select>
        <div class="validation-error" id="state-error"></div>
      </div>
      <div class="col-6 col-md-3">
        <label for="zipcode" class="form-label">Postleitzahl *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" name="zipcode" id="zipcode" maxlength="5" placeholder="" data-required="1">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="zipcode-error"></div>
      </div>
    </div>
    <div class="form-row">
      <div class="col">
        <label for="email" class="form-label">E-Mail-Adresse<i class="email-receipt-instructions">(Für eine Kopie Ihrer Quittung geben Sie Ihre E-Mail-Adresse ein.)</i></label>
        <div class="input-group">
          <input type="text" class="form-control border-right-0" name="email" id="email" placeholder="">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
        <div class="validation-error" id="email-error"></div>
      </div>
    </div>
    <div class="col-12" id="payment-div">
      <span class="page-heading">Zahlungsbetrag</span>
    </div>
    <div class="form-row">
      <div class="col">
        <label for="amount" class="form-label">Betrag *</label>
        <div class="input-group">
          <input type="text" class="form-control billing-elements border-right-0" pattern="^\d{0,6}(\.\d{0,2})?$" name="amount" id="amount" autocomplete="off" data-required="1">
          <span class="input-group-append bg-white border-left-0">
            <span class="input-group-text bg-transparent exclamation-icon-wrapper"><i class="fas fa-exclamation-circle exclamation-icon input-prefix" style="display: none;"></i></span>
          </span>
        </div>
      </div>
    </div>
    <div class="validation-error" id="amount-error"></div>
    <div class="form-row" id="payment-submit-section">
      <div class="col-12">
        <div class="alert alert-danger fade show" id="response-container" role="alert">
          <span id="response-message"></span>
        </div>
      </div>
      <div class="offset-md-8 col-md-4 float-right">
        <input type="hidden" id="csrf_token" name="csrf_token" value="b.AMbG6Q2AFOa-7-JoWzqPMKouKHn978mlbV-7J7dR8wk.UYyLjGvXLNPn2bQNH1j5Rt56Hxu5vrrAIRH3f4AAkE9rh5-_Y_g51NqBpw">
        <input type="hidden" id="query_params" name="query_params" value="{&quot;params_string&quot;:&quot;&quot;}">
        <button type="submit" id="process-bc" class="form-control btn-process" q="">
          <span class="ready">Zahlung übermitteln</span>
          <span class="processing">
            <span>.</span><span>.</span><span>.</span>
          </span>
        </button>
      </div>
    </div>
    <div class="col-12 text-center" style="padding-top:1em;">
      <span></span>
    </div>
  </div>
</form>

POST 

<form method="post" style="display: none;" id="second-step-form"></form>

Text Content

Highland Smiles

--------------------------------------------------------------------------------


Erforderliches Feld *
Highland Smiles
Zusätzliche Informationen
Patient First and Last Name


Zahlungsinformation
Kreditkartennummer *


gültig bis *


Kartenprüfnummer (CVV) *


Vorname *


Nachname *


USA
Straße


Stadt


Bundesland Select AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD
MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA
WV WI WY

Postleitzahl *


E-Mail-Adresse(Für eine Kopie Ihrer Quittung geben Sie Ihre E-Mail-Adresse ein.)


Zahlungsbetrag
Betrag *


Zahlung übermitteln ...


Highland Smiles

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TRANSAKTIONSQUITTUNG

INFORMATIONEN ZUM VERTRAGSPARTNER

--------------------------------------------------------------------------------

Vertragspartner

Datum/Zeit

Transaktions-ID

Art der Transaktion
Credit Card

--------------------------------------------------------------------------------

Betrag


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INFORMATIONEN ZUR KREDITKARTE

--------------------------------------------------------------------------------

Typ

Nummer


ZAHLUNGSINFORMATION

--------------------------------------------------------------------------------

Name

Straße

Stadt, Bundesland, Postleitzahl


ZUSÄTZLICHE INFORMATIONEN

--------------------------------------------------------------------------------


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