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checkup-dic.hospitalesangeles.com Open in urlscan Pro
35.192.117.102  Public Scan

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URL: https://checkup-dic.hospitalesangeles.com/en/
Submission: On June 02 via manual from IN — Scanned from DE

Form analysis 1 forms found in the DOM

Name: formulario1 — POST cuestionario_4.php

<form method="post" name="formulario1" action="cuestionario_4.php">
  <div class="form-group row form-inline">
    <!--<div class="form-group col-md-4">&nbsp;</div>-->
    <div class="form-group col-md-12 text-right">
      <label>Date: </label>&nbsp;&nbsp; <input type="text" class="form-control text-uppercase text-center" id="fecha" name="fecha" value="02-06-2023" disabled="disabled">
      <!--<input type="date" class="form-control text-uppercase" id="fecha" name="fechareg" required="required">-->
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>LAST NAME</label>
      <input type="text" class="form-control text-uppercase" id="ap_pat" name="ap_pat" required="required">
    </div>
    <div class="form-group col-md-4">
      <label>MOTHER´S MAIDEN NAME</label>
      <input type="text" class="form-control text-uppercase" id="am_mat" name="am_mat" required="required">
    </div>
    <div class="form-group col-md-4">
      <label>NAME(S)</label>
      <input type="text" class="form-control text-uppercase" id="nom_pac" name="nom_pac" required="required">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>DATE OF BIRTH</label>
      <input type="date" class="form-control" id="fecha_nac" name="fecha_nac">
    </div>
    <div class="form-group col-md-4">
      <label>GENDER</label>
      <div class="col-sm-10">
        <div class="form-check form-check-inline">
          <input class="form-check-input" type="radio" name="sexo" id="sexo" value="M">
          <label class="form-check-label" for="inlineRadio1">Male</label>
        </div>
        <div class="form-check form-check-inline">
          <input class="form-check-input" type="radio" name="sexo" id="sexo" value="F">
          <label class="form-check-label" for="inlineRadio2">Female</label>
        </div>
      </div>
    </div>
    <div class="form-group col-md-4">
      <label>MARITAL STATUS</label>
      <select class="form-control text-uppercase" id="edo_civil" name="edo_civil">
        <option value="vacio">Select one</option>
        <option value="Single">Single</option>
        <option value="Married">Married</option>
        <option value="Divorced">Divorced</option>
      </select>
      <!--<label>Estado civil</label>
					<input type="text" class="form-control" id="edo_civil" name="edo_civil">-->
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>OCCUPATION</label>
      <input type="text" class="form-control text-uppercase" id="ocupacion" name="ocupacion">
    </div>
    <div class="form-group col-md-4">
      <label>PLACE OF BIRTH</label>
      <input type="text" class="form-control text-uppercase" id="lugarnac" name="lugarnac">
    </div>
    <div class="form-group col-md-4">
      <label>NATIONALITY</label>
      <input type="text" class="form-control text-uppercase" id="nacionalidad" name="nacionalidad">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-8">
      <label for="inputAddress">STREET AND NUMBER</label>
      <input type="text" class="form-control text-uppercase" id="callenum" name="callenum">
    </div>
    <div class="form-group col-md-4">
      <label class="text-uppercase">Colonia</label>
      <input type="text" class="form-control text-uppercase" id="colonia_pac" name="colonia_pac">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label for="inputCity">CITY</label>
      <input type="text" class="form-control text-uppercase" id="ciudad_pac" name="ciudad_pac">
    </div>
    <div class="form-group col-md-4">
      <label for="inputState">Municipality</label>
      <input type="text" class="form-control text-uppercase" id="estado_pac" name="estado_pac">
    </div>
    <div class="form-group col-md-4">
      <label for="inputZip">ZIP CODE</label>
      <input type="number" class="form-control text-uppercase" id="cp_pac" name="cp_pac">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label for="inputCity">TELEPHONE</label>
      <input type="number" class="form-control text-uppercase" id="tel_pac" name="tel_pac">
    </div>
    <div class="form-group col-md-4">
      <label for="inputState">EMAIL</label>
      <input type="text" class="form-control text-uppercase" id="correo_pac" name="correo_pac">
    </div>
  </div>
  <p style="border-bottom: 3px solid #4E4E4E;">In case of emergency please notify:</p><br>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>LAST NAME</label>
      <input type="text" class="form-control text-uppercase" id="pat_em" name="pat_em">
    </div>
    <div class="form-group col-md-4">
      <label>MOTHER´S MAIDEN NAME</label>
      <input type="text" class="form-control text-uppercase" id="mat_em" name="mat_em">
    </div>
    <div class="form-group col-md-4">
      <label>NAME(S)</label>
      <input type="text" class="form-control text-uppercase" id="nombre_em" name="nombre_em">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>RELATION</label>
      <input type="text" class="form-control text-uppercase" id="parentesco" name="parentesco">
    </div>
    <div class="form-group col-md-8">
      <label>STREET AND NUMBER</label>
      <input type="text" class="form-control text-uppercase" id="direc_em" name="direc_em">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label class="text-uppercase">Colonia</label>
      <input type="text" class="form-control text-uppercase" id="colonia_em" name="colonia_em">
    </div>
    <div class="form-group col-md-4">
      <label>CITY</label>
      <input type="text" class="form-control text-uppercase" id="ciudad_em" name="ciudad_em">
    </div>
    <div class="form-group col-md-4">
      <label class="text-uppercase">Municipality</label>
      <input type="text" class="form-control text-uppercase" id="estado_em" name="estado_em">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>ZIP CODE</label>
      <input type="number" class="form-control text-uppercase" id="cp_em" name="cp_em">
    </div>
    <div class="form-group col-md-4">
      <label>TELEPHONE</label>
      <input type="number" class="form-control text-uppercase" id="tel_em" name="tel_em">
    </div>
  </div>
  <p style="border-bottom: 3px solid #4E4E4E;">Information for accounting department</p><br>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>LAST NAME</label>
      <input type="text" class="form-control text-uppercase" id="pat_fact" name="pat_fact">
    </div>
    <div class="form-group col-md-4">
      <label>MOTHER´S MAIDEN NAME</label>
      <input type="text" class="form-control text-uppercase" id="mat_fact" name="mat_fact">
    </div>
    <div class="form-group col-md-4">
      <label>NAME(S)</label>
      <input type="text" class="form-control text-uppercase" id="nombre_fact" name="nombre_fact">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-8">
      <label for="inputAddress">STREET AND NUMBER</label>
      <input type="text" class="form-control text-uppercase" id="direc_fact" name="direc_fact">
    </div>
    <div class="form-group col-md-4">
      <label class="text-uppercase">Colonia</label>
      <input type="text" class="form-control text-uppercase" id="colonia_fact" name="colonia_fact">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>CITY</label>
      <input type="text" class="form-control text-uppercase" id="ciudad_fact" name="ciudad_fact">
    </div>
    <div class="form-group col-md-4">
      <label class="text-uppercase">Municipality</label>
      <input type="text" class="form-control text-uppercase" id="estado_fact" name="estado_fact">
    </div>
    <div class="form-group col-md-4">
      <label>ZIP CODE</label>
      <input type="number" class="form-control text-uppercase" id="cp_fact" name="cp_fact">
    </div>
  </div>
  <div class="form-row">
    <div class="form-group col-md-4">
      <label>TELEPHONE</label>
      <input type="number" class="form-control text-uppercase" id="telefono_fact" name="telefono_fact">
    </div>
    <div class="form-group col-md-4">
      <label>RFC</label>
      <input type="text" class="form-control text-uppercase" id="rfc_fact" name="rfc_fact">
    </div>
  </div>
  <input type="submit" value="Siguiente">
  <!--<input type="hidden" name="boton" value="Guardar">
	<button type="submit" class="btn btn-primary" name="boton" value="Guardar" id="save">Guardar</button>-->
</form>

Text Content



PREVENTIVE MEDICINE UNIT

General Information


Personal Information


Date:   
LAST NAME
MOTHER´S MAIDEN NAME
NAME(S)
DATE OF BIRTH
GENDER
Male
Female
MARITAL STATUS Select one Single Married Divorced
OCCUPATION
PLACE OF BIRTH
NATIONALITY
STREET AND NUMBER
Colonia
CITY
Municipality
ZIP CODE
TELEPHONE
EMAIL

In case of emergency please notify:


LAST NAME
MOTHER´S MAIDEN NAME
NAME(S)
RELATION
STREET AND NUMBER
Colonia
CITY
Municipality
ZIP CODE
TELEPHONE

Information for accounting department


LAST NAME
MOTHER´S MAIDEN NAME
NAME(S)
STREET AND NUMBER
Colonia
CITY
Municipality
ZIP CODE
TELEPHONE
RFC