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patient.payments.health Open in urlscan Pro
2600:9000:2490:d600:17:6716:8ec0:93a1  Public Scan

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Submitted URL: https://payments.brushandfloss.com/
Effective URL: https://patient.payments.health/
Submission: On October 08 via automatic, source certstream-suspicious — Scanned from DE

Form analysis 1 forms found in the DOM

<form>
  <div class="pt-8">
    <div>
      <h3 class="text-xl leading-6 font-medium text-gray-900">Online Bill Pay</h3>
      <p class="mt-1 text-sm text-gray-500">Complete the following form and click pay below.</p>
    </div>
    <div class="mt-5 grid grid-cols-1 gap-y-2 gap-x-4 sm:grid-cols-6">
      <div class="sm:col-span-3"><label for="givenName" class="block text-sm font-medium text-gray-700">Patient First Name<span class="ordinal text-red-600">*</span></label>
        <div class="mt-1"><input type="text" id="givenName" autocomplete="on" class="shadow-sm focus:ring-blue-500 focus:border-blue-500 block w-full sm:text-sm border-gray-300 rounded-md" name="givenName"></div>
      </div>
      <div class="sm:col-span-3"><label for="familyName" class="block text-sm font-medium text-gray-700">Patient Last Name<span class="ordinal text-red-600">*</span></label>
        <div class="mt-1"><input type="text" id="familyName" autocomplete="on" class="shadow-sm focus:ring-blue-500 focus:border-blue-500 block w-full sm:text-sm border-gray-300 rounded-md" name="familyName"></div>
      </div>
      <div class="sm:col-span-3"><label for="patientID" class="block text-sm font-medium text-gray-700">Account Number<span class="ordinal text-red-600">*</span></label>
        <div class="mt-1"><input type="text" id="patientID" class="shadow-sm focus:ring-blue-500 focus:border-blue-500 block w-full sm:text-sm border-gray-300 rounded-md" name="patientID"></div>
      </div>
      <div class="sm:col-span-3"><label for="email" class="block text-sm font-medium text-gray-700">Email</label>
        <div class="mt-1"><input type="email" id="email" autocomplete="on" class="shadow-sm focus:ring-blue-500 focus:border-blue-500 block w-full sm:text-sm border-gray-300 rounded-md" name="email"></div>
      </div>
    </div>
  </div>
  <div class="pt-5 pb-6">
    <div>
      <h3 class="text-lg leading-6 font-medium text-gray-900">Payment Amount<span class="ordinal text-red-600">*</span></h3>
      <p class="mt-1 text-sm text-gray-500">Enter the amount you would like to pay.</p>
    </div>
    <div class="grid grid-cols-1 sm:grid-cols-6">
      <div class="sm:col-span-3">
        <div class="mt-1 bg-white rounded-md shadow-sm -space-y-px">
          <div class="flex -space-x-px"><span class="mt-1 inline-flex items-center px-3 rounded-l-md border border-gray-300 bg-gray-50 text-gray-500 sm:text-sm">$</span>
            <div class="mt-1"><input type="text" id="amount" placeholder="0.00" autocomplete="on" class="border-gray-300 shadow-sm rounded-l-none w-full sm:text-sm rounded-md focus:ring-blue-500 focus:border-blue-500" name="amount"></div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="pb-10">
    <div>
      <h3 class="text-lg leading-6 font-medium text-gray-900 pb-1">Payment Method</h3>
    </div>
    <div class="block w-full focus:ring-blue-500 focus:border-blue-500 border-gray-300 rounded-md" role="tablist" aria-orientation="horizontal">
      <div class="border-b border-gray-200">
        <nav class="-mb-px flex space-x-8" aria-label="Tabs"><button class="border-blue-500 text-blue-600 group inline-flex items-center py-2 px-1 border-b-2 font-medium text-sm" id="headlessui-tabs-tab-:r0:" role="tab" aria-selected="true"
            tabindex="0" data-headlessui-state="selected" type="button" aria-controls="headlessui-tabs-panel-:r1:"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" fill="currentColor" aria-hidden="true"
              class="text-blue-500 block -ml-0.5 mr-2 h-5 w-5">
              <path d="M4.5 3.75a3 3 0 00-3 3v.75h21v-.75a3 3 0 00-3-3h-15z"></path>
              <path fill-rule="evenodd" d="M22.5 9.75h-21v7.5a3 3 0 003 3h15a3 3 0 003-3v-7.5zm-18 3.75a.75.75 0 01.75-.75h6a.75.75 0 010 1.5h-6a.75.75 0 01-.75-.75zm.75 2.25a.75.75 0 000 1.5h3a.75.75 0 000-1.5h-3z" clip-rule="evenodd"></path>
            </svg><span>Credit/Debit Card</span></button></nav>
      </div>
    </div>
    <div class="mt-2.5">
      <div class="sm:col-span-4" id="headlessui-tabs-panel-:r1:" role="tabpanel" tabindex="0" data-headlessui-state="selected" aria-labelledby="headlessui-tabs-tab-:r0:">
        <div data-testid="rswps-form" aria-label="Payment form" id="rswps-form" role="form">
          <div data-testid="rswps-card-container" id="rswps-card-container" style="min-height: 89px;">
            <div id="single-card-wrapper-52099b02-38b3-47d4-5b92-cb5fc090299c" class="sq-card-wrapper sq-focus">
              <div class="sq-card-iframe-container" style="height: 48px;"><iframe frameborder="0" height="48px" name="single-card-52099b02-38b3-47d4-5b92-cb5fc090299c" scrolling="no"
                  src="https://web.squarecdn.com/1.60.9/single-card-element-iframe.html" width="100%" class="sq-card-component"></iframe></div><span class="sq-card-message sq-card-message-no-error sq-visible">Enter your card number</span>
            </div>
          </div><button aria-disabled="false" id="rswp-card-button" type="button" class="c-jWYnUm c-jWYnUm-iidqHoJ-css">Pay Amount</button>
        </div>
      </div>
    </div>
  </div>
</form>

Text Content

You need to enable JavaScript to run this app.


ONLINE BILL PAY

Complete the following form and click pay below.

Patient First Name*

Patient Last Name*

Account Number*

Email



PAYMENT AMOUNT*

Enter the amount you would like to pay.

$



PAYMENT METHOD

Credit/Debit Card

Enter your card number
Pay Amount
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