contactinfo.mlh.org
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198.254.16.101
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Submitted URL: https://contactinfo.mlh.org/
Effective URL: https://contactinfo.mlh.org/Default.aspx
Submission: On February 19 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://contactinfo.mlh.org/Default.aspx
Submission: On February 19 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
POST ./Default.aspx
<form method="post" action="./Default.aspx" id="form1" data-toggle="validator">
<div class="aspNetHidden">
<input type="hidden" name="__EVENTTARGET" id="__EVENTTARGET" value="">
<input type="hidden" name="__EVENTARGUMENT" id="__EVENTARGUMENT" value="">
<input type="hidden" name="__VIEWSTATE" id="__VIEWSTATE"
value="kM9vGGWrLGvS3ZZwVI/qHbW/GbdVHUAxC8itLWkNWIH9n+qaLfdMCy0ID9rL3uXs1bscaUQaEf52/OoFX4ptjsJm1L5pbpkTedOokyEUiiTMy8v2cky93AF7rWCet+X8tyD+XJ04Un5goBQte+/UCWFi9fFYitE/MP6SHyTFWBPggMcf0pBQo7ARoVQlekTH6g5Q1LNYjwkpOLTafx6y8I+flHCKZODUuBSRZzD+6G0Nli1Gi72WJFxh1P3vlSRZ1bVJGtP3tdOMgW7Hz6u3KgaRk0UNMy80FBP8ZvH7fy8XiOteXI+qeeKrNzCDZ3a59UIIN7YbNTO4IkaT4txgE6oSzaFlDizQZOH+0QNzkXI=">
</div>
<script type="text/javascript">
//<![CDATA[
var theForm = document.forms['form1'];
if (!theForm) {
theForm = document.form1;
}
function __doPostBack(eventTarget, eventArgument) {
if (!theForm.onsubmit || (theForm.onsubmit() != false)) {
theForm.__EVENTTARGET.value = eventTarget;
theForm.__EVENTARGUMENT.value = eventArgument;
theForm.submit();
}
}
//]]>
</script>
<script src="/WebResource.axd?d=pynGkmcFUV13He1Qd6_TZLk4sR2GxIWh0qhtbvxj83orEEMF7c_oQyLPpxmKSohlIkaOqUakVKT4APqvNjEp1w2&t=638393210639266807" type="text/javascript"></script>
<script src="/ScriptResource.axd?d=uHIkleVeDJf4xS50Krz-yMpO3TNLiPGENkV06zXAfLIQLkaCZCB6GGFPB1KStU6cG5-WNh2I8q1MZdzS4X3gtpjQRQX_f6xd2vrKkYcyNs7kwFkJitU5AphxY7YQWFGdXqT-kDxCRFtuHWXApjyFq3q47PRZ9AZs1T3mM7yEYgI1&t=3cf0aaa4" type="text/javascript">
</script>
<script src="/ScriptResource.axd?d=Jw6tUGWnA15YEa3ai3FadGw7Pt2xPgh9xTNu7uPO-L9BDzCXZvVKjDrC80XA35MQ2-1j-rV9pNZGbD7VGyCqeDMtknbbOLhcpuAQIo6EsDidVEdI1orJ5BTGI6w1I9h-GBSnxQ_9vCD8g2R_5052Bpn18tO0A7wsesRP0dtE-AI1&t=3cf0aaa4" type="text/javascript">
</script>
<script src="js/SWNNonAssoc.js" type="text/javascript"></script>
<div class="aspNetHidden">
<input type="hidden" name="__VIEWSTATEGENERATOR" id="__VIEWSTATEGENERATOR" value="CA0B0334">
<input type="hidden" name="__EVENTVALIDATION" id="__EVENTVALIDATION"
value="HOIvr6c+SYqQ63Jp5Pbpi/VLx2bSz4TG7lzm3KZtHMuNesWgQfaNBZFyvUuJDqOezjZPQMOr5QeUhGWkls5Uod9KPU7SaWQ88RKwVO3ILjYkfdjvsNzOCU7NcRx3dUvpIr+nIsb//WQcF95aBoSk3ctGUj25eFcBkKrRNOAy0u2gHZUAb+9Ki5m3/AqUHFOQw6AqsDbFuR7G6A8A662PTEXnjh0e7snCauA2IK5vU3osgNPxVs7vIOhMF/cyPXI3d3zgdbXf/auooYzhphzoIg==">
</div>
<div>
<div class="navbar navbar-inverse navbar-static-top" style="background: url("css/images/img-paint-blue.jpg") 0px -120px repeat-x rgb(255, 255, 255); border-color: rgb(255, 255, 255);">
<div class="container">
<div class="navbar-header">
<button type="button" class="navbar-toggle" data-toggle="collapse" data-target=".navbar-collapse">
<span class="icon-bar"></span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
</button>
<a class="mlhLogo" href="https://secureapps.methodisthealth.org/Prescreen/"></a>
</div>
</div>
</div>
<div class="container body-content">
<br>
<script type="text/javascript">
$(document).ready(function() {
loadCaptcha();
});
function loadCaptcha() {
$.ajax({
type: 'GET',
url: 'Home/generateCaptcha',
contentType: "application/json; charset=utf-8",
dataType: "json",
cache: false,
success: function(data) {
$("#m_imgCaptcha").attr('src', data);
},
error: function(data) {
alert("Error while loading captcha image")
}
});
}
function validateCaptcha(value) {
if (value == "false") {
$("#lblCaptcha").text("Enter a valid captcha");
$("input[placeholder^='Captcha']").val("");
loadCaptcha();
$('#ctl00$MainContent$btnSubmit').prop('disabled', true);
} else {
$("#lblCaptcha").text("");
$('#MainContent_btnSubmit').prop('disabled', false);
}
}
function modalShowSuccess() {
$("#divAlertInfo").text("Your form has been submitted successfully.");
$('#modalShowSuccess').modal('show');
}
</script>
<h2 style="margin: 0px auto 0px auto;"><span>Non-Associate Contact Info</span> </h2>
<hr style="margin: 5px auto 5px auto;">
<p class="text-danger">
</p>
<script type="text/javascript">
//<![CDATA[
Sys.WebForms.PageRequestManager._initialize('ctl00$MainContent$ScriptManager1', 'form1', ['tctl00$MainContent$upnlPatInfo', 'MainContent_upnlPatInfo'], ['ctl00$MainContent$btnSubmit', 'MainContent_btnSubmit'], [], 240, 'ctl00');
//]]>
</script>
<div id="MainContent_upnlPatInfo">
<script type="text/javascript">
Sys.Application.add_load(swnScript);
</script>
<div id="MainContent_divNewForm" class="form-horizontal">
<div class="main container-fluid" id="main">
<span id="MainContent_lblPrevData" style="color:Red;"></span>
<span id="MainContent_lblResult" class="error"></span>
<span id="MainContent_lblAlert" class="required"></span>
</div>
<br>
<br>
<input type="hidden" name="ctl00$MainContent$hfvUserAgent" id="MainContent_hfvUserAgent" value="Desktop/Laptop">
<div id="MainContent_divWaiting" class="modalLoad"></div>
<div class="form-group">
<label for="MainContent_ddlFacilityName" class="col-md-3 control-label">Facility Name:<em class="text-danger">*</em></label>
<div class="col-md-4">
<div class="col-md-11">
<select name="ctl00$MainContent$ddlFacilityName" id="MainContent_ddlFacilityName" align="right" maxlength="60" multiple="" style="min-width: 100%"
class="col-md-offset-4 form-control form-control-sm lbhDropDown select2-hidden-accessible" tabindex="-1" aria-hidden="true">
<option value="Germantown">Germantown</option>
<option value="LeBonheur">LeBonheur</option>
<option value="MPB">MPB</option>
<option value="North">North</option>
<option value="OB">OB</option>
<option value="South">South</option>
<option value="University">University</option>
</select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 300px;"><span class="selection"><span class="select2-selection select2-selection--multiple" role="combobox" aria-haspopup="true"
aria-expanded="false" tabindex="-1">
<ul class="select2-selection__rendered">
<li class="select2-search select2-search--inline"><input class="select2-search__field" type="search" tabindex="0" autocomplete="off" autocorrect="off" autocapitalize="off" spellcheck="false" role="textbox"
aria-autocomplete="list" placeholder="Select Facility" style="width: 298px;"></li>
</ul>
</span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
</div>
<div class="col-md-1" style="padding-left: 0px">
<img id="img" class="toolTipHTML" data-ttipcontent="ttip_facilitydropdown" src="css/images/info.png" alt="" title=""
data-original-title="Press and hold control button to select more than one facility. Select your current facility and also the facility and any other facilities you will be at.">
</div>
</div>
</div>
<div class="form-group">
<label for="MainContent_txtFName" class="col-md-3 control-label">First Name:<em class="text-danger">*</em></label>
<div class="col-md-4">
<div class="col-md-11">
<input name="ctl00$MainContent$txtFName" type="text" maxlength="30" id="MainContent_txtFName" class="txtCtrl form-control" placeholder="FirstName" style="min-width: 100%">
</div>
</div>
</div>
<div class="form-group">
<label for="MainContent_txtLName" class="col-md-3 control-label">Last Name:<em class="text-danger">*</em></label>
<div class="col-md-4">
<div class="col-md-11">
<input name="ctl00$MainContent$txtLName" type="text" maxlength="30" id="MainContent_txtLName" class="txtCtrl form-control" placeholder="LastName" style="min-width: 100%">
</div>
</div>
</div>
<div class="form-group">
<label for="MainContent_txtPhone" class="col-md-3 control-label">Phone:<em class="text-danger">*</em></label>
<div class="col-md-4">
<div class="col-md-11">
<input name="ctl00$MainContent$txtPhone" type="text" maxlength="12" id="MainContent_txtPhone" class="txtCtrl form-control" placeholder="Phone" style="min-width: 100%">
<span id="lblError" style="color: red"></span>
</div>
<div class="col-md-1" style="padding-left: 0px">
<img src="css/images/info.png" id="MainContent_img2" align="right" class="toolTipHTML" alt="" title="" data-original-title=" Enter a valid 10 digit mobile phone number to receive text alerts.">
</div>
</div>
</div>
<div class="form-group">
<label for="MainContent_txtEmail" class="emailLbl col-md-3 control-label">Email:</label>
<div class="col-md-4">
<div class="col-md-11">
<input name="ctl00$MainContent$txtEmail" type="text" maxlength="60" id="MainContent_txtEmail" class="email txtCtrl form-control" data-trigger="manual" data-placement="auto top" placeholder="Email" data-error="Invalid email address."
style="min-width: 100%">
<span id="lblInvalidEmail" style="color: red"></span>
</div>
<div class="col-md-1" style="padding-left: 0px">
<img src="css/images/info.png" id="MainContent_img1" align="right" class="toolTipHTML" alt="" title="" data-original-title="Enter a valid Email">
</div>
</div>
</div>
<div class="form-group">
<label class="emailLbl col-md-3 control-label"></label>
<div class="col-md-4">
<div class="col-md-11" style="text-align: left !important">
<img id="m_imgCaptcha" alt="Click to Change image" align="left" src="/captchaImages/rw1fuqtfr4hcnpv3ezakv3s4.png?t=638439517611926421" title="Click to Change image" onclick="loadCaptcha();" style="width: 200px; height: 60px;">
</div>
</div>
</div>
<div class="form-group">
<label for="MainContent_txtLName" class="col-md-3 control-label">Captcha:<em class="text-danger">*</em></label>
<div class="col-md-4">
<div class="col-md-11">
<input name="ctl00$MainContent$txtCaptcha" type="text" maxlength="5" id="MainContent_txtCaptcha" class="txtCtrl form-control" placeholder="Captcha" style="min-width: 100%">
<span id="lblCaptcha" style="color: red"></span>
</div>
</div>
</div>
<div class="form-group">
<div class="col-md-offset-3 col-md-11">
<div class="col-md-11">
<span id="MainContent_m_lbMessage"></span>
</div>
</div>
</div>
<div class="form-group">
<div class="col-md-offset-3 col-md-4">
<div class="col-md-11">
<input type="submit" name="ctl00$MainContent$btnSubmit" value="Submit" id="MainContent_btnSubmit" class="btn btn-sm lbhButton" style="width:75px;" disabled="">
</div>
</div>
</div>
<div id="modalShowSuccess" class="modal fade" role="dialog">
<div class="modal-dialog modal-lg alert alert-success">
<div class="modal-content">
<div class="modal-header">
<button type="button" class="close" data-dismiss="modal">×</button>
<div class="modal-title">
<h2 style="margin: 0px; text-align: left">Thank You</h2>
</div>
</div>
<div class="modal-body row">
<div class="col-md-2">
<i class="glyphicon glyphicon-leaf" id="green-leaf"></i>
</div>
<div id="divAlertInfo" style="padding: 0px 15px 5px 0px; text-align: center;" class="col-md-10"></div>
</div>
<div class="modal-footer" id="modal-footer">
<button class="mybtn" data-dismiss="modal">Close</button>
</div>
</div>
</div>
</div>
</div>
</div>
<footer class="footer text-center">
<hr style="margin:10px auto 5px auto;">
<p>© 2024 - Methodist Le Bonheur Healthcare. All Rights Reserved.</p>
</footer>
</div>
</div>
</form>Text Content
NON-ASSOCIATE CONTACT INFO -------------------------------------------------------------------------------- Facility Name:* Germantown LeBonheur MPB North OB South University * First Name:* Last Name:* Phone:* Email: Captcha:* × THANK YOU Close -------------------------------------------------------------------------------- © 2024 - Methodist Le Bonheur Healthcare. All Rights Reserved.