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Submission: On December 13 via api from US — Scanned from US
Submission: On December 13 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
POST /#gf_1
<form method="post" enctype="multipart/form-data" id="gform_1" action="/#gf_1">
<div id="gf_progressbar_wrapper_1" class="gf_progressbar_wrapper">
<h3 class="gf_progressbar_title">Step <span class="gf_step_current_page">1</span> of <span class="gf_step_page_count">2</span>
</h3>
<div class="gf_progressbar gf_progressbar_blue" aria-hidden="true">
<div class="gf_progressbar_percentage percentbar_blue percentbar_50" style="width:50%;"><span>50%</span></div>
</div>
</div>
<div class="gform_body gform-body">
<div id="gform_page_1_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_1" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_12" class="gfield gfield_price gfield_price_1_12 gfield_product_1_12 field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_12"><label class="gfield_label"
for="input_1_12">Price</label>
<div class="ginput_container ginput_container_product_price">
<input name="input_12" id="input_1_12" type="text" value="" class="medium ginput_amount" placeholder="$0.00" aria-invalid="false">
</div>
</li>
<li id="field_1_13" class="gfield field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_13"><label class="gfield_label" for="input_1_13">Account Number</label>
<div class="ginput_container ginput_container_text"><input name="input_13" id="input_1_13" type="text" value="" class="medium" aria-invalid="false"> </div>
</li>
<li id="field_1_2" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_2"><label class="gfield_label gfield_label_before_complex">Name<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name" id="input_1_2">
<span id="input_1_2_3_container" class="name_first">
<input type="text" name="input_2.3" id="input_1_2_3" value="" aria-required="true">
<label for="input_1_2_3">First</label>
</span>
<span id="input_1_2_6_container" class="name_last">
<input type="text" name="input_2.6" id="input_1_2_6" value="" aria-required="true">
<label for="input_1_2_6">Last</label>
</span>
</div>
</li>
<li id="field_1_3" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><label class="gfield_label gfield_label_before_complex">Address<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address" id="input_1_3">
<span class="ginput_full address_line_1 ginput_address_line_1" id="input_1_3_1_container">
<input type="text" name="input_3.1" id="input_1_3_1" value="" aria-required="true">
<label for="input_1_3_1" id="input_1_3_1_label">Street Address</label>
</span><span class="ginput_full address_line_2 ginput_address_line_2" id="input_1_3_2_container">
<input type="text" name="input_3.2" id="input_1_3_2" value="" aria-required="false">
<label for="input_1_3_2" id="input_1_3_2_label">Address Line 2</label>
</span><span class="ginput_left address_city ginput_address_city" id="input_1_3_3_container">
<input type="text" name="input_3.3" id="input_1_3_3" value="" aria-required="true">
<label for="input_1_3_3" id="input_1_3_3_label">City</label>
</span><span class="ginput_right address_state ginput_address_state" id="input_1_3_4_container">
<select name="input_3.4" id="input_1_3_4" aria-required="true">
<option value="" selected="selected"></option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="American Samoa">American Samoa</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Guam">Guam</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New Mexico">New Mexico</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Northern Mariana Islands">Northern Mariana Islands</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Puerto Rico">Puerto Rico</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="U.S. Virgin Islands">U.S. Virgin Islands</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
<option value="Armed Forces Americas">Armed Forces Americas</option>
<option value="Armed Forces Europe">Armed Forces Europe</option>
<option value="Armed Forces Pacific">Armed Forces Pacific</option>
</select>
<label for="input_1_3_4" id="input_1_3_4_label">State</label>
</span><span class="ginput_left address_zip ginput_address_zip" id="input_1_3_5_container">
<input type="text" name="input_3.5" id="input_1_3_5" value="" aria-required="true">
<label for="input_1_3_5" id="input_1_3_5_label">ZIP Code</label>
</span><input type="hidden" class="gform_hidden" name="input_3.6" id="input_1_3_6" value="United States">
<div class="gf_clear gf_clear_complex"></div>
</div>
</li>
<li id="field_1_4" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><label class="gfield_label" for="input_1_4">Email<span
class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_container ginput_container_email">
<input name="input_4" id="input_1_4" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_1_5" class="gfield gfield_price gfield_price_1_ gfield_total gfield_total_1_ field_sublabel_below field_description_below gfield_visibility_visible" aria-atomic="true" aria-live="polite" data-js-reload="field_1_5"><label
class="gfield_label" for="input_1_5">Total</label>
<div class="ginput_container ginput_container_total">
<span class="ginput_total ginput_total_1">$0.00</span>
<input type="hidden" name="input_5" id="input_1_5" class="gform_hidden" value="0">
</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label">
<input type="button" id="gform_next_button_1_9" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_10" class="gfield gfield_price gfield_price_1_ gfield_total gfield_total_1_ field_sublabel_below field_description_below gfield_visibility_visible" aria-atomic="true" aria-live="polite" data-js-reload="field_1_10"><label
class="gfield_label" for="input_1_10">Total</label>
<div class="ginput_container ginput_container_total">
<span class="ginput_total ginput_total_1">$0.00</span>
<input type="hidden" name="input_10" id="input_1_10" class="gform_hidden" value="0">
</div>
</li>
<li id="field_1_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><label class="gfield_label gfield_label_before_complex" for="input_1_7_1">Credit
Card<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label>
<div class="ginput_complex ginput_container ginput_container_creditcard" id="input_1_7"><span class="ginput_full" id="input_1_7_1_container">
<div class="gform_card_icon_container">
<div class="gform_card_icon gform_card_icon_amex">American Express</div>
<div class="gform_card_icon gform_card_icon_discover">Discover</div>
<div class="gform_card_icon gform_card_icon_mastercard">MasterCard</div>
<div class="gform_card_icon gform_card_icon_visa">Visa</div><span class="screen-reader-text" id="field_1_7_supported_creditcards">Supported Credit Cards: American Express, Discover, MasterCard, Visa</span>
</div>
<input type="text" name="input_7.1" id="input_1_7_1" value="" onchange="gformMatchCard("input_1_7_1");" onkeyup="gformMatchCard("input_1_7_1");" aria-required="true">
<label for="input_1_7_1" id="input_1_7_1_label">Card Number</label>
</span><span class="ginput_full ginput_cardextras" id="input_1_7_2_container">
<span class="ginput_cardinfo_left" id="input_1_7_2_cardinfo_left">
<span class="ginput_card_expiration_container ginput_card_field">
<select name="input_7.2[]" id="input_1_7_2_month" class="ginput_card_expiration ginput_card_expiration_month" aria-required="true">
<option value="">Month</option>
<option value="1">01</option>
<option value="2">02</option>
<option value="3">03</option>
<option value="4">04</option>
<option value="5">05</option>
<option value="6">06</option>
<option value="7">07</option>
<option value="8">08</option>
<option value="9">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select name="input_7.2[]" id="input_1_7_2_year" class="ginput_card_expiration ginput_card_expiration_year" aria-required="true">
<option value="">Year</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
<option value="2031">2031</option>
<option value="2032">2032</option>
<option value="2033">2033</option>
<option value="2034">2034</option>
<option value="2035">2035</option>
<option value="2036">2036</option>
<option value="2037">2037</option>
<option value="2038">2038</option>
<option value="2039">2039</option>
<option value="2040">2040</option>
<option value="2041">2041</option>
<option value="2042">2042</option>
</select>
</span>
<label for="input_1_7_2_month">Expiration Date</label>
</span><span class="ginput_cardinfo_right" id="input_1_7_2_cardinfo_right">
<input type="text" name="input_7.3" id="input_1_7_3" class="ginput_card_security_code" value="" aria-required="true">
<span class="ginput_card_security_code_icon"> </span>
<label for="input_1_7_3">Security Code</label>
</span>
</span><span class="ginput_full" id="input_1_7_5_container">
<input type="text" name="input_7.5" id="input_1_7_5" value="" aria-required="false">
<label for="input_1_7_5" id="input_1_7_5_label">Cardholder Name</label>
</span> </div>
</li>
<li id="field_1_8" class="gfield field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_8"><label class="gfield_label" for="input_1_8">CAPTCHA</label>
<div id="input_1_8" class="ginput_container ginput_recaptcha gform-initialized" data-sitekey="6LeqtOMZAAAAAA4OcCD0rdnprPA3LUSVskoitLim" data-theme="light" data-tabindex="0" data-badge="">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-pj6afzllorl2" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LeqtOMZAAAAAA4OcCD0rdnprPA3LUSVskoitLim&co=aHR0cHM6Ly9mdXR1cmVkaWFnbm9zdGljcy5obXNwYXkuY29tOjQ0Mw..&hl=en&v=u-xcq3POCWFlCr3x8_IPxgPu&theme=light&size=normal&cb=qwq7mxaywk8b"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_1" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; jQuery("#gform_1").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_1" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; jQuery("#gform_1").trigger("submit",[true]); }">
<input type="hidden" class="gform_hidden" name="is_submit_1" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="1">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_1" value="WyJbXSIsIjUxZWI4YTM2ZTZmYWY4YjE3OTFjZmE0ZWYzZWIxNDI2Il0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_1" id="gform_target_page_number_1" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_1" id="gform_source_page_number_1" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
</form>Text Content
Skip to the content Future Diagnostics Menu * Future Diagnostics Group Online Payment Close Menu * Future Diagnostics Group Online Payment FUTURE DIAGNOSTICS GROUP ONLINE PAYMENT STEP 1 OF 2 50% * Price * Account Number * Name* First Last * Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code * Email* * Total $0.00 * Total $0.00 * Credit Card* American Express Discover MasterCard Visa Supported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20232024202520262027202820292030203120322033203420352036203720382039204020412042 Expiration Date Security Code Cardholder Name * CAPTCHA Merchant Services provided by Host Merchant Services © 2023 Future Diagnostics Powered by WordPress To the top ↑ Up ↑ Notifications