package.zaynax.health
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116.68.196.78
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URL:
https://package.zaynax.health/
Submission: On February 07 via automatic, source certstream-suspicious — Scanned from DE
Submission: On February 07 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
<form novalidate="" class="overflow-hidden" autocomplete="off">
<div class="styles__FormWrapper-sc-oqwmm8-0 euFhdh">
<div class="main-form">
<div class=" border-bottom px-5 row">
<div class="col-md-12">
<div class="styles__PickerWrapper-sc-1ff728s-2 kgHVUC">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label required="" class="styles__FormLabel-sc-6ssgli-1 jaYHox">Packages</label>
<div style="border-radius:18px" class="SelectPicker__FormHeaderWrapper-sc-luke4e-0 ljGQCL py-4 w-100 position-relative p-3">
<div class="image-box"><img src="/images/defualt-image.png" class=""></div>
<div class="ml-3">
<p style="font-size:10px" class="m-0 p-0">You are purchasing</p><input required="" value="Please Select A Package" name="packageName" placeholder="Choose Package" readonly="" class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
</div>
<div class="styles__Indicator-sc-1ff728s-0 hqVUVm"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" width="20" height="20">
<path d="M12 13.172l4.95-4.95 1.414 1.414L12 16 5.636 9.636 7.05 8.222z" fill="#000"></path>
</svg></div>
</div>
<p class="styles__FormFeedback-sc-6ssgli-3 iiTaaF"></p>
</div>
</div>
</div>
</div>
<div class="px-5">
<h3 style="font-size:20px;font-weight:400" class="mt-5 mb-3">Applicant Info</h3>
<div>
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label required="" class="styles__FormLabel-sc-6ssgli-1 jaYHox">Phone Number</label><input required="" name="phoneNumber" placeholder="Enter Phone Number" value=""
class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
<p class="styles__FormFeedback-sc-6ssgli-3 iiTaaF"></p>
</div>
</div>
<div class="d-flex flex-lg-nowrap flex-wrap align-items-center">
<div class="w-100 mr-0 mr-lg-3">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label required="" class="styles__FormLabel-sc-6ssgli-1 jaYHox">First Name</label><input type="text" required="" name="firstName" value="" class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
<p class="styles__FormFeedback-sc-6ssgli-3 iiTaaF"></p>
</div>
</div>
<div class="w-100">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label class="styles__FormLabel-sc-6ssgli-1 hIjvHA">Last Name</label><input type="text" name="lastName" value="" class="styles__FormControl-sc-6ssgli-2 eCFrPJ"></div>
</div>
</div>
<div class="d-flex flex-lg-nowrap flex-wrap align-items-center">
<div class="w-100 mr-0 mr-lg-3">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label required="" class="styles__FormLabel-sc-6ssgli-1 jaYHox">Date of Birth</label><input type="date" required="" name="dateOfBirth" value=""
class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
<p class="styles__FormFeedback-sc-6ssgli-3 iiTaaF"></p>
</div>
</div>
<div class="w-100">
<div class="styles__PickerWrapper-sc-1ff728s-2 kgHVUC">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label required="" class="styles__FormLabel-sc-6ssgli-1 jaYHox">Gender</label>
<div class="w-100 position-relative"><input required="" value="" name="gender" placeholder="Select" readonly="" class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
<div class="styles__Indicator-sc-1ff728s-0 hqVUVm"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" width="20" height="20">
<path d="M12 13.172l4.95-4.95 1.414 1.414L12 16 5.636 9.636 7.05 8.222z" fill="var(--border)"></path>
</svg></div>
</div>
<p class="styles__FormFeedback-sc-6ssgli-3 iiTaaF"></p>
</div>
</div>
</div>
</div>
<div class="d-flex flex-lg-nowrap flex-wrap">
<div class="w-100 mr-0 mr-lg-3">
<div class="styles__PickerWrapper-sc-1ff728s-2 kgHVUC">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label class="styles__FormLabel-sc-6ssgli-1 hIjvHA">Identity Verification Document Type</label>
<div class="w-100 position-relative"><input value="" name="identityVerificationDocumentType" placeholder="Select" readonly="" class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
<div class="styles__Indicator-sc-1ff728s-0 hqVUVm"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" width="20" height="20">
<path d="M12 13.172l4.95-4.95 1.414 1.414L12 16 5.636 9.636 7.05 8.222z" fill="var(--border)"></path>
</svg></div>
</div>
</div>
</div>
</div>
<div class="w-100">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label class="styles__FormLabel-sc-6ssgli-1 hIjvHA">Identity Verification Number</label><input name="identityVerificationNumber" value="" placeholder="NID/Smart Card Number"
class="styles__FormControl-sc-6ssgli-2 eCFrPJ"></div>
</div>
</div>
<div class="mt-4">
<h3 style="font-size:20px;font-weight:400" class="mb-3">Nominee Info <span style="color:#848484">(optional)</span></h3>
<div class="d-flex flex-lg-nowrap flex-wrap">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi w-100 w-lg-50 mr-0 mr-lg-3"><label class="styles__FormLabel-sc-6ssgli-1 hIjvHA">Mobile Number</label><input name="nomineePhoneNumber" value="" placeholder="Enter nominee's mobile number"
class="styles__FormControl-sc-6ssgli-2 eCFrPJ"></div>
<div class="w-100 w-lg-50">
<div class="styles__PickerWrapper-sc-1ff728s-2 kgHVUC">
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label class="styles__FormLabel-sc-6ssgli-1 hIjvHA">Relationship</label>
<div class="w-100 position-relative"><input value="" name="relationshipWithNominee" placeholder="Select" readonly="" class="styles__FormControl-sc-6ssgli-2 eCFrPJ">
<div class="styles__Indicator-sc-1ff728s-0 hqVUVm"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" width="20" height="20">
<path d="M12 13.172l4.95-4.95 1.414 1.414L12 16 5.636 9.636 7.05 8.222z" fill="var(--border)"></path>
</svg></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="mt-4">
<h3 style="font-size:20px;font-weight:400" class="mb-3">Referral Info <span style="color:#848484">(optional)</span></h3>
<div class="styles__FormGroup-sc-6ssgli-0 ilnIgi"><label class="styles__FormLabel-sc-6ssgli-1 hIjvHA">Referral Code</label><input placeholder="Enter referral code" name="referralCode" class="styles__FormControl-sc-6ssgli-2 eCFrPJ"></div>
</div>
</div>
</div>
</div>
<div class="styles__StickyFooter-sc-oqwmm8-1 nvwrF shadow-lg">
<div class="wrapper">
<div class="d-flex flex-lg-nowrap flex-wrap justify-content-between">
<div class="w-100 w-lg-50 w-xs-100 mb-3 mb-lg-0 d-flex justify-content-start align-items-center">
<p class="p-0 m-0" style="font-size:18px">Total Payable:</p>
<h5 class="ml-3" style="font-size:20px">0<!-- --> <!-- -->TK</h5>
</div><button style="background-color:#ff0065" class="styles__ButtonWrapper-sc-1szs3h0-0 jPOltC w-100 w-lg-50 border-0" type="submit" disabled="">Submit</button>
</div>
<div class="mt-1 d-flex align-items-center justify-content-center text-center flex-wrap" style="font-size:13px">
<div class="d-flex align-items-start">
<div class="styles__CheckboxGroup-sc-1eoqhuu-0 eWcjlc"><input type="checkbox" class="styles__CheckboxInput-sc-1eoqhuu-1 fbuYSb mr-2 mt-1"><label class="styles__CheckboxLabel-sc-1eoqhuu-2 dtUifi"></label></div>
<p>By clicking on “Next” you are agreeing with all of our</p>
</div>
<a style="color:#ff0065;margin-left:4px" href="https://zaynaxhealth.com/terms-and-conditions/" class="p-0 nav-link"> <!-- -->Terms & Conditions<!-- --> </a>-<a style="color:#ff0065;margin-left:4px" href="https://zaynaxhealth.com/privacy-policy/" class="p-0 nav-link"> <!-- -->Privacy Policy</a>-<a style="color:#ff0065;margin-left:4px" href="https://zaynaxhealth.com/refund-policy/" class="p-0 nav-link"> <!-- -->Refund-Return policy</a>
</div>
</div>
</div>
<div class="Confirmation__Wrapper-sc-9ai9yw-0 bMGoTk">
<div class="d-flex justify-content-end align-items-center">
<div><button style="margin:0;padding:0;background-color:transparent;border:none"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" width="24" height="24">
<path d="M12 10.586l4.95-4.95 1.414 1.414-4.95 4.95 4.95 4.95-1.414 1.414-4.95-4.95-4.95 4.95-1.414-1.414 4.95-4.95-4.95-4.95L7.05 5.636" fill="#AFAFAF"></path>
</svg></button></div>
</div>
<div class="p-1 text-center">
<p class="mb-3">An OTP has been sent to your phone number</p>
<div class="mb-3 d-flex justify-content-center flex-wrap align-items-center">
<div class="m-2"><span></span></div><button style="background-color:transparent;border:none;text-decoration:underline">Edit</button>
</div>
<p style="color:#6BB8D7">Enter OTP</p>
<div class="d-flex justify-content-center my-4">
<div style="display:flex">
<div style="display:flex;align-items:center"><input type="tel" aria-label="Please enter verification code. Digit 1" autocomplete="off" style="width:45px;text-align:center;height:45px" class="" maxlength="1" value=""><span>-</span></div>
<div style="display:flex;align-items:center"><input type="tel" aria-label="Digit 2" autocomplete="off" style="width:45px;text-align:center;height:45px" class="" maxlength="1" value=""><span>-</span></div>
<div style="display:flex;align-items:center"><input type="tel" aria-label="Digit 3" autocomplete="off" style="width:45px;text-align:center;height:45px" class="" maxlength="1" value=""><span>-</span></div>
<div style="display:flex;align-items:center"><input type="tel" aria-label="Digit 4" autocomplete="off" style="width:45px;text-align:center;height:45px" class="" maxlength="1" value=""><span>-</span></div>
<div style="display:flex;align-items:center"><input type="tel" aria-label="Digit 5" autocomplete="off" style="width:45px;text-align:center;height:45px" class="" maxlength="1" value=""><span>-</span></div>
<div style="display:flex;align-items:center"><input type="tel" aria-label="Digit 6" autocomplete="off" style="width:45px;text-align:center;height:45px" class="" maxlength="1" value=""></div>
</div>
</div><button style="background-color:#ff0065" class="styles__ButtonWrapper-sc-1szs3h0-0 jPOltC border-0" disabled="" type="button">Verify and Submit</button>
<p class="pt-3">Please wait <!-- -->60<!-- --> seconds before you can resend OTP</p>
</div>
</div>
</form>Text Content
English Need Help? Packages You are purchasing APPLICANT INFO Phone Number First Name Last Name Date of Birth Gender Identity Verification Document Type Identity Verification Number NOMINEE INFO (OPTIONAL) Mobile Number Relationship REFERRAL INFO (OPTIONAL) Referral Code Total Payable: 0 TK Submit By clicking on “Next” you are agreeing with all of our Terms & Conditions - Privacy Policy- Refund-Return policy An OTP has been sent to your phone number Edit Enter OTP - - - - - Verify and Submit Please wait 60 seconds before you can resend OTP