skin-scan.fiveminutes.com.au
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139.99.131.128
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URL:
https://skin-scan.fiveminutes.com.au/
Submission Tags: phishingrod
Submission: On February 04 via api from DE — Scanned from AU
Submission Tags: phishingrod
Submission: On February 04 via api from DE — Scanned from AU
Form analysis 1 forms found in the DOM
POST includes/registration.php
<form id="signup" method="POST" action="includes/registration.php" style="width:100%;" novalidate="novalidate">
<!-- You can switch " data-color="orange" " with one of the next bright colors: "blue", "green", "orange", "red", "azure" -->
<div class="wizard-header text-center">
<h3 class="wizard-title">Patient Registration</h3>
<p class="category">Please assist us by completing the following.</p>
</div>
<div class="wizard-navigation">
<div class="progress-with-circle">
<div class="progress-bar" role="progressbar" aria-valuenow="1" aria-valuemin="1" aria-valuemax="3" style="width: 16.6667%;"></div>
</div>
<ul style="display:none;" class="nav nav-pills">
<li class="active" style="width: 33.3333%;">
<a href="#about" data-toggle="tab" aria-expanded="true">
<div class="icon-circle checked">
<i class="ti-user"></i>
</div>
About
</a>
</li>
<li style="width: 33.3333%;">
<a href="#account" data-toggle="tab">
<div class="icon-circle">
<i class="ti-settings"></i>
</div>
Work
</a>
</li>
<li style="width: 33.3333%;">
<a href="#address" data-toggle="tab">
<div class="icon-circle">
<i class="ti-map"></i>
</div>
Address
</a>
</li>
<!-- <li>
<a href="#terms" data-toggle="tab">
<div class="icon-circle">
<i class="ti-map"></i>
</div>
Terms
</a>
</li>-->
</ul>
</div>
<div class="tab-content">
<div class="tab-pane active" id="about">
<div class="row">
<div style="float:right; width:100%; font-size:14px; font-weight:bold; text-align:center; margin-right:30px; margin-top:-40px;">Step 1 of 3</div>
<h5 class="info-text" style="padding-left:15px; font-size:20px; font-weight:bold; text-align:left;"> Please tell us more about yourself.</h5>
<div class="col-sm-4" style="padding-right:0px;">
<div class="form-group">
<div class="input-group input-group-lg">
<div class="input-group-addon mrselerror">
<select name="mrsel" id="mrsel" style="background:none; border:0px;">
<option value="">Title</option>
<option value="Mr">Mr.</option>
<option value="Mrs">Mrs.</option>
<option value="Master">Master.</option>
<option value="Miss">Miss.</option>
</select>
</div>
<div class="surnameerror">
<input name="surname" maxlength="30" type="text" class="form-control" placeholder="Surname *" style="clear:both; border:1px solid #ccc; border-radius: 0px 4px 4px 0px;">
</div>
</div>
</div>
</div>
<div class="col-sm-3" style="padding-right:0px;">
<div class="form-group">
<input name="firstname" maxlength="30" type="text" class="form-control" placeholder="First Name *">
</div>
</div>
<div class="col-sm-5">
<div class="input-group">
<div class="input-group-addon"> DOB <i class="fa fa-calendar"></i>
</div>
<!-- onkeyup="this.value=this.value.replace(/^(\d\d)(\d)$/g,'$1/$2').replace(/^(\d\d\/\d\d)(\d+)$/g,'$1/$2').replace(/[^\d\/]/g,'')"-->
<!--<input class="form-control" onkeyup="this.value=this.value.replace(/^(\d\d)(\d)$/g,'$1/$2').replace(/^(\d\d\/\d\d)(\d+)$/g,'$1/$2').replace(/[^\d\/]/g,'')" id="dateofbirth" name="dob" required placeholder="DD/MM/YYYY" type="text" style="padding-left:10px;" />-->
<select class="dob_select" name="dob_date" id="dob_date" style="width:30%" required="" aria-required="true">
<option>DD</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
</select>
<select class="dob_select" name="dob_month" id="dob_month" style="width:30%" required="" aria-required="true">
<option>MM</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select class="dob_select" name="dob_year" id="dob_year" style="width:40%" required="" aria-required="true">
<option>YYYY</option>
<option value="2024">2024</option>
<option value="2023">2023</option>
<option value="2022">2022</option>
<option value="2021">2021</option>
<option value="2020">2020</option>
<option value="2019">2019</option>
<option value="2018">2018</option>
<option value="2017">2017</option>
<option value="2016">2016</option>
<option value="2015">2015</option>
<option value="2014">2014</option>
<option value="2013">2013</option>
<option value="2012">2012</option>
<option value="2011">2011</option>
<option value="2010">2010</option>
<option value="2009">2009</option>
<option value="2008">2008</option>
<option value="2007">2007</option>
<option value="2006">2006</option>
<option value="2005">2005</option>
<option value="2004">2004</option>
<option value="2003">2003</option>
<option value="2002">2002</option>
<option value="2001">2001</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
<option value="1949">1949</option>
<option value="1948">1948</option>
<option value="1947">1947</option>
<option value="1946">1946</option>
<option value="1945">1945</option>
<option value="1944">1944</option>
<option value="1943">1943</option>
<option value="1942">1942</option>
<option value="1941">1941</option>
<option value="1940">1940</option>
<option value="1939">1939</option>
<option value="1938">1938</option>
<option value="1937">1937</option>
<option value="1936">1936</option>
<option value="1935">1935</option>
<option value="1934">1934</option>
<option value="1933">1933</option>
<option value="1932">1932</option>
<option value="1931">1931</option>
<option value="1930">1930</option>
<option value="1929">1929</option>
<option value="1928">1928</option>
<option value="1927">1927</option>
<option value="1926">1926</option>
<option value="1925">1925</option>
<option value="1924">1924</option>
<option value="1923">1923</option>
<option value="1922">1922</option>
<option value="1921">1921</option>
<option value="1920">1920</option>
<option value="1919">1919</option>
<option value="1918">1918</option>
<option value="1917">1917</option>
<option value="1916">1916</option>
<option value="1915">1915</option>
<option value="1914">1914</option>
<option value="1913">1913</option>
<option value="1912">1912</option>
<option value="1911">1911</option>
<option value="1910">1910</option>
<option value="1909">1909</option>
<option value="1908">1908</option>
<option value="1907">1907</option>
<option value="1906">1906</option>
<option value="1905">1905</option>
<option value="1904">1904</option>
</select>
</div>
<span id="dateofbirth2" style="margin-top:-10px;"></span>
</div>
<div class="clearfix"></div>
<div class="col-sm-4">
<div class="form-group">
<label style="margin-right:10px;">Gender *</label>
<label><input name="gender" type="radio" checked="" value="M"> Male</label>
<label><input name="gender" type="radio" value="F"> Female</label>
</div>
</div>
<div class="col-sm-8">
<div class="form-group ethnicityerror">
<label style="margin-right:10px;">Ethnicity *</label>
<label><input name="ethnicity" type="radio" onclick="ethnicityout();" value="Australian"> Australian</label>
<label><input name="ethnicity" type="radio" onclick="ethnicityout();" value="Aboriginal"> Aboriginal</label>
<label><input name="ethnicity" type="radio" onclick="ethnicityout();" value="Torres Strait Islander">Torres Strait Islander</label>
<label><input name="ethnicity" type="radio" onclick="ethnicityin();" value="Other"> Other</label>
</div>
</div>
<div class="col-sm-6" style="padding-left:0px; padding-top:10px; padding-right:0px; border-right:1px solid #cccccc;">
<div class="col-sm-12">
<div class="form-group">
<label style="font-size:10px;">Medicare Card Number</label>
<input type="tel" pattern="\d*" maxlength="10" name="medicare" class="form-control" placeholder="Medicare Card Number *">
</div>
</div>
<div class="col-sm-4" style="padding-right:0px;">
<div class="form-group">
<input type="tel" pattern="\d*" maxlength="1" name="refno" class="form-control" placeholder="Ref No *">
</div>
</div>
<div class="col-sm-8">
<div class="form-group">
<input type="text" id="mediexpiry" name="mexpiry" class="form-control" placeholder="Expiry:MM/YY *">
</div>
</div>
</div>
<div class="col-sm-6" style="padding-left:0px; padding-top:10px; padding-right:0px;">
<div class="col-sm-12">
<div class="form-group">
<label style="font-size:10px;">DVA Number</label>
<input type="text" pattern="\d*" maxlength="14" name="dvanumber" id="dvanumber" class="form-control" placeholder="DVA Number">
</div>
</div>
<div class="col-sm-5" style="padding-right:0px; margin-right:0px; margin-top:5px;">
<div class="form-group">
<label><input name="card" type="radio" value="Gold" disabled=""> Gold</label>
<label><input name="card" type="radio" value="White" disabled=""> White</label>
</div>
</div>
<div class="col-sm-7" style="padding-left:0px;">
<div class="form-group">
<input type="text" id="dvaexpiry" name="dvaexpiry" disabled="" class="form-control" placeholder="Expiry:MM/YY">
</div>
</div>
</div>
<div id="Concession" class="col-sm-12" style="padding-left:0px; padding-top:10px;">
<div class="col-sm-6 healtherror">
<div class="form-group" style="margin-top:5px; margin-bottom:18px;">
<label><input name="health" id="health" type="radio" value="No Concession"> No Concession</label>
<label><input name="health" type="radio" value="Pension Card"> Pension</label>
<label><input name="health" type="radio" value="Health Care Card"> Health Care</label>
</div>
</div>
<div class="col-sm-6" style="padding-right:0px;">
<div class="form-group">
<input type="text" pattern="\d*" maxlength="14" name="pensionhealth" class="form-control" id="pensionhealth" placeholder="Pension/Health Care Card Number *">
</div>
</div>
</div>
<div class="col-sm-12" style="font-size:10px; padding-left:20px; margin-top:0px;margin-bottom:12px;">If you are an eligible concession card holder and do not have your card on you, leave the above field blank. Please contact the reception.
</div>
</div>
</div>
<div class="tab-pane" id="account">
<div style="float:right; width:100%; font-size:14px; font-weight:bold; text-align:center; margin-right:30px; margin-top:-40px;">Step 2 of 3</div>
<h5 class="info-text" style="font-size:20px; font-weight:bold; text-align:left;"> Address </h5>
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<input name="streetaddress" maxlength="40" type="text" class="form-control" placeholder="Street Address">
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<!-- <select name="suburb" id="suburb" class="form-control" placeholder="Suburb" style="">
</select> -->
<input id="suburb" name="suburb" type="text" class="form-control" placeholder="Suburb..." data-select2-id="suburb">
<div id="suburbDiv"></div>
</div>
</div>
<div class="col-sm-2">
<div class="form-group">
<input name="state" id="state" type="text" class="form-control" placeholder="State">
</div>
</div>
<div class="col-sm-2" style="padding-left:0px; padding-right:0px;">
<div class="form-group">
<input name="postcode" id="pincode" maxlength="4" type="text" class="form-control" placeholder="Postcode">
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<input name="postal" type="text" class="form-control" placeholder="(If different Postal Address)">
</div>
</div>
<div class="col-sm-12">
<div class="form-group" style="margin-bottom:0px;">
<h5 class="info-text" style="font-size:20px; font-weight:bold; text-align:left;"> Contact Details </h5>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input name="cmobile" type="text" class="form-control" placeholder="Mobile *">
</div>
</div>
<div class="col-sm-4">
<div class="form-group">
<input name="emailaddress" id="emailaddress1" type="email" class="form-control" placeholder="Email Address">
</div>
</div>
<div class="col-sm-2">
<div class="form-group">
<label style="display:inline-block; float:left; cursor:pointer;"><input id="noemail" name="noemail" type="checkbox" onclick="onClickHandler()"> No Email</label>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input name="chome" maxlength="14" type="text" class="form-control" placeholder="Home">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input name="cwork" maxlength="14" type="text" class="form-control" placeholder="Work">
</div>
</div>
</div>
</div>
<div class="tab-pane" id="address">
<div style="float:right; width:100%; font-size:14px; font-weight:bold; text-align:center; margin-right:30px; margin-top:-40px;">Step 3 of 3</div>
<h5 class="info-text" style="font-size:20px; font-weight:bold; text-align:left;"> Key Contact Information </h5>
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<label>Next of Kin Contact</label>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="kinfirstname" name="kinfirstname" type="text" class="form-control" placeholder="First Name *">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="kinlastname" name="kinlastname" type="text" class="form-control" placeholder="Last Name *">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="kincontact" maxlength="14" name="kincontact" type="text" class="form-control" placeholder="Contact Number *">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="kinrelationship" name="kinrelationship" type="text" class="form-control" placeholder="Relationship *">
</div>
</div>
<div class="col-sm-12">
<div class="form-group">
<input type="checkbox" id="same" name="same" onchange="addressFunction()">
<label for="same">If same as Key Contact Information.</label>
</div>
</div>
<div class="col-sm-12">
<div class="form-group">
<label>Emergency Contact</label>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="emefirstname" name="emefirstname" type="text" class="form-control" placeholder="First Name">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="emelastname" name="emelastname" type="text" class="form-control" placeholder="Last Name">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="emecontact" name="emecontact" type="text" class="form-control" placeholder="Contact Number">
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<input id="emerelationship" name="emerelationship" type="text" class="form-control" placeholder="Relationship">
</div>
</div>
<div class="row">
<div class="col-sm-12">
<div class="col-sm-12 termsconditionserror" style="padding-left:0px;">
<p class="col-sm-12 form-group" style="margin-bottom:20px; margin-top:10px;"><label style="float:left; width:100%; margin-right:10px;">How did you come to know about us?</label>
<label><input name="knowaboutout" type="radio" value="Online Booking" onclick="knowaboutout();"> Online Booking</label>
<label><input name="knowaboutout" type="radio" value="website" onclick="knowaboutout();" style="margin-left:20px;"> Website</label>
<label><input name="knowaboutout" type="radio" value="Google Search" onclick="knowaboutout();" style="margin-left:20px;"> Google Search</label>
<label><input name="knowaboutout" type="radio" value="recommended" onclick="knowaboutout();" style="margin-left:20px;"> Recommended</label>
<label><input name="knowaboutout" type="radio" value="other" onclick="knowaboutin();" style="margin-left:20px;"> Other</label>
</p>
<p class="col-sm-12" id="knowabout" style="display:none; margin-bottom:20px;"><input id="knowaboutus" name="knowaboutus_oth" type="text" class="form-control" placeholder=""></p>
<p class="col-sm-6 form-group termstrueerror" style="margin-bottom:20px;"><label style="display:inline-block; float:left; margin-right:10px;"><label><input name="terms_conditions" type="checkbox" value="yes"> I agree to the</label>
<a href="#" data-toggle="modal" data-target="#myModal">Terms and Conditions</a></label></p>
<p class="col-sm-6 form-group" style="margin-bottom:20px;"><label style="display:inline-block; float:left; margin-right:10px;"><label><input name="terms_true" type="checkbox" value="yes"> I confirm the above is true</label></label></p>
</div>
</div>
</div>
</div>
</div>
<div class="wizard-footer">
<div class="pull-right">
<input type="button" class="btn btn-next btn-fill btn-warning btn-wd" name="next" id="next" value="Next">
<input type="submit" class="btn btn-finish btn-fill btn-warning btn-wd" name="finish" value="Finish" style="display: none;">
</div>
<div class="pull-left">
<input type="button" class="btn btn-previous btn-default btn-wd disabled" name="previous" value="Previous">
</div>
<div class="clearfix"></div>
</div>
</div>
</form>Text Content
PATIENT REGISTRATION
Please assist us by completing the following.
*
About
*
Work
*
Address
Step 1 of 3
PLEASE TELL US MORE ABOUT YOURSELF.
Title Mr. Mrs. Master. Miss.
DOB
DD01020304050607080910111213141516171819202122232425262728293031
MM010203040506070809101112
YYYY2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201919191819171916191519141913191219111910190919081907190619051904
Gender * Male Female
Ethnicity * Australian Aboriginal Torres Strait Islander Other
Medicare Card Number
DVA Number
Gold White
No Concession Pension Health Care
If you are an eligible concession card holder and do not have your card on you,
leave the above field blank. Please contact the reception.
Step 2 of 3
ADDRESS
CONTACT DETAILS
No Email
Step 3 of 3
KEY CONTACT INFORMATION
Next of Kin Contact
If same as Key Contact Information.
Emergency Contact
How did you come to know about us? Online Booking Website Google Search
Recommended Other
I agree to the Terms and Conditions
I confirm the above is true
×
TERMS AND CONDITIONS
1. All patient information is private and confidentiality of patient
information must be maintained at all times. The rights of every patient are
to be respected. All information collected by this practice in providing a
health service is deemed to be private and confidential.
2. This practice complies with Federal and State privacy regulations including
the Privacy Act 1998, the Privacy Amendment (Private Sector) Act 2000 and
Victorian Health Records Act 2001 as well as the standards set out in the
RACGP Handbook for the Management of Health Information in Private Medical
Practice 1st Edition (2002). (Refer Section 6 Privacy and Security of Health
Information).
3. Under no circumstances are employees of this practice to discuss or in any
way reveal patient conditions or documentation to unauthorised staff,
colleagues, other patients, family or friends, whether at the practice or
outside it, such as in the home or at social occasions. This includes
patient’s accounts, referral letters or other clinical documentation.
4. General Practitioners and staff are aware of confidentiality requirements
for all patient encounters and recognise that significant breaches of
confidentiality may provide grounds for disciplinary action or dismissal.
5. Every employee of this practice is aware of the privacy policy and has
signed a privacy statement as part of their terms and conditions of
employment. This privacy statement continues to be binding on employees even
after their employment has terminated.
6. As a part of our practice policy, we do send SMS and emails for recalls,
reminders and other health promotions.
7. You agree to receiving your test results and other correspondences via
email.
Close