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Form analysis
1 forms found in the DOM

POST Payment/PayMultipleInvoice

<form action="Payment/PayMultipleInvoice" method="post">
  <table width="100%">
    <thead>
      <tr>
        <th class="text-left">Invoice Number</th>
        <th class="text-left">Date of Birth</th>
        <th></th>
        <th class="text-right">Amount (£)</th>
        <th></th>
      </tr>
    </thead>
    <tbody data-bind="foreach: invoices">
      <tr>
        <td class="custom-td" data-label="Invoice Number">
          <div class="form-group">
            <input class="form-control invoiceNumber" id="invoiceNumber" style="text-transform: uppercase" data-bind="textInput: invoiceReference" placeholder="XX/111/1" autocomplete="off">
          </div>
        </td>
        <td class="custom-td" data-label="Date of Birth">
          <div class="form-group">
            <input type="date" class="form-control" id="dateOfBirth" data-bind="textInput: dateOfBirth" maxlength="10" max="9999-12-31">
          </div>
        </td>
        <td>
          <div class="form-group">
            <input type="button" class="btn btn-primary btn-sm" id="loadBtn" value="Load" title="Load Amount" data-bind="click: $root.loadAmount">
          </div>
        </td>
        <td data-label="Amount (£)">
          <div class="form-group InvoiceAmo">
            <input class="form-control pull-right text-right invoiceAmount" data-bind="numeric, textInput:invoiceAmount, enable: amountIsEnabled, attr:{id:'InvoiceId_' + invoiceID()}, event: {'keyup':$parent.amountKeyup, 'blur':$parent.amountBlur }"
              align="right" disabled="" id="InvoiceId_0">
            <input class="hidden" data-bind="value: actualInvoiceAmount,attr:{id:'InvoiceIdHidden_' + invoiceID()}" id="InvoiceIdHidden_0">
          </div>
        </td>
        <td>
          <div class="form-group">
            <a id="removeInvoice" class="btn btn-primary btn-sm" href="#" data-bind="click: $root.removeInvoice" title="Delete Invoice"><span class="glyphicon glyphicon-minus"></span></a>
          </div>
        </td>
      </tr>
    </tbody>
  </table>
  <input class="hidden" id="invoicesList" name="data" data-bind="value: jsonInvoices">
  <button class="hidden" id="MakePaymentBtn">save</button>
</form>

Text Content

Invoice payment

Welcome to the Civica Medical Billing and Collection Patient Payment Portal
Please enter your invoice details below

Please enter Invoice Number, Date of Birth, and select Load

Invoice Number Date of Birth Amount (£)






save

Total surcharge: 0.00

Add Invoice Retrieve all invoices Refresh Clear dates View Paid Invoice

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Make Payment

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Civica Medical Billing and Collection
Connery House
Repton Place
Amersham
Buckinghamshire HP7 9LP