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teletesting.rsroemani.com Open in urlscan Pro
103.82.240.51  Public Scan

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URL: http://teletesting.rsroemani.com/
Submission: On December 16 via api from US — Scanned from US

Form analysis 1 forms found in the DOM

POST 

<form method="POST" class="mt-5 mb-5 login-input" id="form_login">
  <div class="form-group" data-toggle="tooltip" data-placement="top" title="" data-original-title="Contoh : 13-11-52">
    <input type="text" class="form-control" placeholder="No Rekam Medis" id="no_rm" name="no_rm" required="">
  </div>
  <div class="form-group" data-toggle="tooltip" data-placement="top" title="" data-original-title="Contoh : 01-09-1995">
    <input type="text" class="form-control" placeholder="Tanggal Lahir (tgl-bln-thn)" id="tgl_lahir" name="tgl_lahir" maxlength="10" required="">
  </div>
  <button type="submit" class="btn login-form__btn submit w-100">Sign In</button>
</form>

Text Content

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