a00010.d-medis.id Open in urlscan Pro
2606:4700:3035::ac43:a61d  Public Scan

Form analysis
3 forms found in the DOM

Name: loginform — POST login_act.php

<form name="loginform" method="post" action="login_act.php" class="form">
  <!--begin::Title-->
  <div class="pb-13 pt-lg-0 pt-5">
    <h3 class="font-weight-bolder text-dark font-size-h4 font-size-h1-lg">Selamat Datang di <br>e-Klinik</h3>
  </div>
  <!--begin::Title-->
  <!--begin::Form group-->
  <div class="form-group">
    <label class="font-size-h6 font-weight-bolder text-dark">Kode Klinik</label>
    <input autocomplete="off" class="form-control form-control-solid h-auto py-7 px-6 rounded-lg" type="text" name="txt_kode" id="kode_klinik" style="font-size:16px">
  </div>
  <div class="form-group">
    <label class="font-size-h6 font-weight-bolder text-dark">Username</label>
    <input autocomplete="off" class="form-control form-control-solid h-auto py-7 px-6 rounded-lg" type="text" name="txt_name" id="name" style="font-size:16px">
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group">
    <div class="d-flex justify-content-between mt-n5">
      <label class="font-size-h6 font-weight-bolder text-dark pt-5">Kata Sandi</label>
    </div>
    <input autocomplete="off" class="form-control form-control-solid h-auto py-7 px-6 rounded-lg" type="password" name="txt_pass" id="pass" style="font-size:16px">
  </div>
  <!--end::Form group-->
  <!--begin::Action-->
  <div class="pb-lg-0 pb-5" style="text-align: right;">
    <button type="submit" id="kt_login_signin_submit" class="btn btn-primary font-weight-bolder font-size-h6 px-8 py-4 my-3 mr-3">Masuk</button>
  </div>
  <!--end::Action-->
</form>

<form class="form" novalidate="novalidate" id="kt_login_signup_form">
  <!--begin::Title-->
  <div class="pb-13 pt-lg-0 pt-5">
    <h3 class="font-weight-bolder text-dark font-size-h4 font-size-h1-lg">Sign Up</h3>
    <p class="text-muted font-weight-bold font-size-h4">Enter your details to create your account</p>
  </div>
  <!--end::Title-->
  <!--begin::Form group-->
  <div class="form-group">
    <input class="form-control form-control-solid h-auto py-7 px-6 rounded-lg font-size-h6" type="text" placeholder="Fullname" name="fullname" autocomplete="off">
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group">
    <input class="form-control form-control-solid h-auto py-7 px-6 rounded-lg font-size-h6" type="email" placeholder="Email" name="email" autocomplete="off">
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group">
    <input class="form-control form-control-solid h-auto py-7 px-6 rounded-lg font-size-h6" type="password" placeholder="Password" name="password" autocomplete="off">
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group">
    <input class="form-control form-control-solid h-auto py-7 px-6 rounded-lg font-size-h6" type="password" placeholder="Confirm password" name="cpassword" autocomplete="off">
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group">
    <label class="checkbox mb-0">
      <input type="checkbox" name="agree">I Agree the <a href="#">terms and conditions</a>. <span></span></label>
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group d-flex flex-wrap pb-lg-0 pb-3">
    <button type="button" id="kt_login_signup_submit" class="btn btn-primary font-weight-bolder font-size-h6 px-8 py-4 my-3 mr-4">Submit</button>
    <button type="button" id="kt_login_signup_cancel" class="btn btn-light-primary font-weight-bolder font-size-h6 px-8 py-4 my-3">Cancel</button>
  </div>
  <!--end::Form group-->
</form>

<form class="form" novalidate="novalidate" id="kt_login_forgot_form">
  <!--begin::Title-->
  <div class="pb-13 pt-lg-0 pt-5">
    <h3 class="font-weight-bolder text-dark font-size-h4 font-size-h1-lg">Forgotten Password ?</h3>
    <p class="text-muted font-weight-bold font-size-h4">Enter your email to reset your password</p>
  </div>
  <!--end::Title-->
  <!--begin::Form group-->
  <div class="form-group">
    <input class="form-control form-control-solid h-auto py-7 px-6 rounded-lg font-size-h6" type="email" placeholder="Email" name="email" autocomplete="off">
  </div>
  <!--end::Form group-->
  <!--begin::Form group-->
  <div class="form-group d-flex flex-wrap pb-lg-0">
    <button type="button" id="kt_login_forgot_submit" class="btn btn-primary font-weight-bolder font-size-h6 px-8 py-4 my-3 mr-4" data-style="zoom-in">Submit</button>
    <button type="button" id="kt_login_forgot_cancel" class="btn btn-light-primary font-weight-bolder font-size-h6 px-8 py-4 my-3">Cancel</button>
  </div>
  <!--end::Form group-->
</form>

Text Content

KAMI SEDIAKAN ANDA MANFAATKAN


SELAMAT DATANG DI
E-KLINIK

Kode Klinik
Username
Kata Sandi
Masuk


SIGN UP

Enter your details to create your account





I Agree the terms and conditions.
Submit Cancel


FORGOTTEN PASSWORD ?

Enter your email to reset your password


Submit Cancel