my.wellspan.org Open in urlscan Pro
205.172.187.226  Public Scan

Form analysis
1 forms found in the DOM

POST /MyWellSpan/accesscheck.asp

<form autocomplete="off" method="post" action="/MyWellSpan/accesscheck.asp" id="signupForm" csp-guid-submit="4F6ADD93F25E4354A8805095013D9ECD">
  <div class="formcontents">
    <div class="hidden"><input type="hidden" class="hidden" name="sec_token" value="5D581BDB75C24F179CEE11027315175F" autocomplete="off"></div>
    <div class="hidden"><input type="hidden" class="hidden" name="instactsignuptoken" value="4B33B5DC411D4F0EAD1615D6BF24A346" autocomplete="off"></div>
    <div id="locale_container" class="prelogin">
      <a href="/MyWellSpan/accesscheck.asp?InstAct=WP-24u4FOGTvOQy2OsEaAM92b5NiZeiE33IJhcJr4-2BMTTgcQ-3D-24e27BOOqUwpm6aTDGOGPlXVl9P5wkWIrweK08Lzsaw6I-3D&amp;lang=espanol" csp-guid-click="D5C4A93098A547CD8E93A5ECE2E1A673"><span class="localename">Ver en Español</span><abbr class="abbreviatedname" title="Ver en Español">Esp</abbr></a>
    </div>
    <div class="title">
      <h1 class="header">MyWellSpan Signup</h1>
      <div id="assistiveicons"><img class="assistiveicon" alt="" src="/MyWellSpan/en-US/images/space.gif"></div>
    </div><input type="hidden" class="hidden" name="instactcode" value="vJWjDggTZJXZfKPvYkTKGgXX" autocomplete="off"><input type="hidden" class="hidden" name="instactqueryparam"
      value="WP-24u4FOGTvOQy2OsEaAM92b5NiZeiE33IJhcJr4-2BMTTgcQ-3D-24e27BOOqUwpm6aTDGOGPlXVl9P5wkWIrweK08Lzsaw6I-3D" autocomplete="off">
    <div id="loginDiv">
      <div id="signuperror" class="alert signUpFieldError"></div>
      <div class="formsection">
        <label for="login">MyWellSpan username</label><input class="jsreq" type="text" id="login" name="Login" value="" maxlength="128" autocorrect="off" autocomplete="off">
      </div>
    </div>
    <div id="Loginerror" class="alert signUpFieldError"></div>
    <div id="passwordDiv">
      <div id="passwordFieldDiv" class="formsection">
        <label for="Password" id="PasswordLabel"> <span class="label">Create password</span>
        </label><a href="#" id="pwdButton"><img id="pwdButtonImg" src="/MyWellSpan/en-US/images/info_grey.png" alt="Screen readers: use read next line command to hear password guidelines." title="" csp-guid-click="F0BF9749B4874B1DAA0F8B28B00ED585"></a><input
          type="password" name="Password" id="Password" csp-guid-keyup="92B388CF29764276B309A27F3DFE8382" csp-guid-blur="4809AEB090114CD193CA7850C983CBAC" width="90%" autocomplete="off"><input class="hidden" type="text" name="PasswordText"
          id="PasswordText" csp-guid-keyup="92B388CF29764276B309A27F3DFE8382" csp-guid-blur="4809AEB090114CD193CA7850C983CBAC" width="90%" autocorrect="off" autocomplete="off">
        <div id="pwdGuidelines">
          <div id="pwdInstructions" class="hidden">Must contain at least: <ul>
              <li>One lowercase letter.</li>
              <li>One uppercase letter.</li>
              <li>One number.</li>
              <li>One special character.</li>
            </ul>
          </div>
        </div><button type="button" id="showPwd" name="showPwd" csp-guid-click="DA02C3FB005A472BA1BC3A69B7464F99" autocomplete="off">Show</button>
      </div>
      <div id="LoginPassworderror" class="alert signUpFieldError">
      </div>
    </div>
    <div id="passwordStrength">
      <div id="pwdStrLabel">Password strength<br style="display: none;"></div>
      <div id="pwdStrengthDiv0"></div>
      <div id="pwdStrengthDiv50"></div>
      <div id="pwdStrengthDiv75"></div>
      <div id="pwdStrengthDiv100"></div>
      <div id="passwordStrengthWords"></div>
    </div>
    <div id="verificationItemsDiv">
      <script nonce="" type="text/javascript">
        var sEmptyFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter your date of birth."),
          sInvalidFieldErrorDOB = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid date of birth.");
      </script>
      <fieldset class="formsection">
        <legend class="compact header small">Date of birth</legend><label class="clearlabel inlinelabel" for="dob1">Month of birth</label>
        <div class="segment2"><input class="jsreq" type="number" name="dob" id="dob1" maxlength="2" value="" csp-guid-keyup="B5BEC2145D614606AE5EF7AD1DC11A88" csp-guid-keydown="383B5DD8B3CB4728B65B138153AC527F"
            csp-guid-blur="FC8605AA14874FA189F13145BC675B61" csp-guid-click="8E9577B43D8F4DBB8B08ADFCC10FE134" csp-guid-keypress="D43EAB10E9014D7DACBF8495F3664E5E" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">mm</div>
        </div><span class="separator subtle" aria-hidden="true">/</span><label class="clearlabel inlinelabel" for="dob2">Day of birth</label>
        <div class="segment2"><input class="jsreq" type="number" name="dob" id="dob2" maxlength="2" value="" csp-guid-keyup="4BCDEAF21F8C44D48C3772212AA7A20A" csp-guid-keydown="955F56F1DA9648FDBCCEB04C9D855AC4"
            csp-guid-blur="DDB61C7D02924921B36ACC30ECEE6550" csp-guid-click="0C27ADDD802E4840B8A5430EBD962BAB" csp-guid-keypress="74934E9D1CF44C50BCD3DD6C56121698" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">dd</div>
        </div><span class="separator subtle" aria-hidden="true">/</span><label class="clearlabel inlinelabel" for="dob3">Year of birth</label>
        <div class="segment4"><input class="jsreq" type="number" name="dob" id="dob3" maxlength="4" value="" csp-guid-keyup="3D186A22FC8A41CDAFA3A30374543168" csp-guid-keydown="B0AC73545F1C491FA421543D2E2114F3"
            csp-guid-blur="BFE24624FE024CE59C2CBEDB70947C99" csp-guid-click="37675DA9AAD9416D8F0A4C1F815FECF9" csp-guid-keypress="37A726DD474C47B88733E0E543F47C02" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">yyyy</div>
        </div>
        <div id="doberror" class="signUpFieldError"></div>
      </fieldset>
      <div class="formsection"><label for="ssn4" class="header small compact">Social Security number (last 4 digits)</label>
        <script nonce="" type="text/javascript">
          var sEmptyFieldErrorssn4 = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Please enter the last 4 digits of your Social Security number.");
          var sInvalidFieldErrorssn4 = HTMLUnencode("&lt;span class=&quot;clearlabel&quot;&gt;Error: &lt;/span&gt;Invalid last 4 digits of Social Security number.");
        </script>
        <div class="segment4"><input class="jsreq" type="password" name="ssn4" id="ssn4" value="" maxlength="4" csp-guid-keyup="837DA81100544321A8120F1F0AC325FA" csp-guid-blur="EE51690E0E45441AA4DC2E4433C46856" autocomplete="off">
          <div class="helptext accessibleLabel" aria-hidden="true">nnnn</div>
        </div>
        <div id="ssn4error" class="signUpFieldError"></div>
      </div>
    </div>
    <div id="secResponsesDiv"></div> <input class="button jsreq completeworkflow" type="submit" name="instactsignup" id="instactsignup" value="Submit" title="" autocomplete="off">
  </div>
</form>

Text Content

Ver en EspañolEsp


MYWELLSPAN SIGNUP


MyWellSpan username

Create password
Must contain at least:
 * One lowercase letter.
 * One uppercase letter.
 * One number.
 * One special character.

Show

Password strength






Date of birthMonth of birth
mm
/Day of birth
dd
/Year of birth
yyyy

Social Security number (last 4 digits)
nnnn