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2606:4700:4400::ac40:9011  Public Scan

Form analysis
1 forms found in the DOM

POST /Oneidentity/Registration/Register

<form method="post" action="/Oneidentity/Registration/Register" id="register-form" class="register-form common-validate-form" novalidate="novalidate">
  <input name="__RequestVerificationToken" type="hidden" value="cpeTZ628I_xpm0xmyQvY-I385BWO7wCEA_MG70sU5Q5KsCVs0zxQ71kEwyZvZOH2LPf4axqihzXCNS8jDZrkf2Ii_zdFfB7ThieIJ0bD66A1">
  <h3 class="primary-heading">Create your new Bupa digital account</h3>
  <p class="account-para">Already used Bupa Touch or Be.Me before? Use those sign-in details <a href="/oneidentity/login?appType=touchdashboard" class="login-link">here</a></p>
  <div class="row">
    <div class="col-12">
      <div class="info-terms-wrapper">
        <span class="info-icon">
          <img src="/~/media/Images/global/components/common/icons/i-icon.svg" alt="Registration Info">
        </span>
        <label class="info-terms-heading">
          <p class="subheading"><strong>Make sure all details are exactly as they appear on your Bupa documents.</strong></p>
          <p>This lets us link the digital account to you. <a class="overlay-trigger" href="" data-overlay-id="where-can-i-find-them">Where can I find these details?</a></p>
        </label>
      </div>
    </div>
  </div>
  <input id="AppType" name="AppType" type="hidden" value="touchdashboard">
  <div class="register-form-wrapper">
    <div class="row">
      <div class="col-12">
        <div class="form-group">
          <label>Please provide personal details as they appear on your Bupa documents</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12">
        <div class="form-group">
          <label>First name</label>
          <p class="overlay-content">As it appears on your Bupa documents. <a class="overlay-trigger" href="" data-overlay-id="what-do-you-mean">What do you mean?</a></p>
          <div class="row">
            <div class="col-12 col-sm-7 col-lg-5 offset-lg-7">
              <input class="form-control firstNameApostropheConvert text-box single-line" data-val="true" data-val-required="The FirstName field is required." datarequired="Please enter a valid name" id="FirstName" name="FirstName" type="text"
                value="">
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12 col-sm-7 col-lg-5 offset-lg-7">
        <div class="form-group">
          <label>Last name</label>
          <input class="form-control lastNameApostropheConvert text-box single-line" data-val="true" data-val-required="The LastName field is required." datarequired="Please enter a valid name" id="LastName" name="LastName" type="text" value="">
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12">
        <div class="form-group">
          <label>Postcode</label>
          <p class="overlay-content">As it appears on your Bupa documents. <a class="overlay-trigger" href="" data-overlay-id="moved-recently">What if I've moved recently?</a></p>
          <div class="row">
            <div class="col-12 col-sm-7 col-lg-5 offset-lg-7">
              <input class="form-control text-box single-line" data-val="true" data-val-regexwithoptions="The field  must match the regular expression '^([A-Za-z][A-Ha-hJ-Yj-y]?[0-9][A-Za-z0-9]? ?[0-9][A-Za-z]{2}|[Gg][Ii][Rr] ?0[Aa]{2})$'."
                data-val-regexwithoptions-flags="i" data-val-regexwithoptions-pattern="^([A-Za-z][A-Ha-hJ-Yj-y]?[0-9][A-Za-z0-9]? ?[0-9][A-Za-z]{2}|[Gg][Ii][Rr] ?0[Aa]{2})$" data-val-required="The PostCode field is required."
                datarequired="Please enter a valid postcode" id="PostCode" name="PostCode" type="text" validpostcodeattribute="Please enter a valid postcode" value="">
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12 col-sm-7 col-lg-5 offset-lg-7">
        <div class="form-group">
          <div class="date-wrapper">
            <label>Date of birth<span class="date-format"></span></label>
            <div class="date-input-box">
              <input type="text" class="c-date no-key-validation" placeholder="DD" maxlength="2" inputmode="numeric"><span class="date-saperator">/</span>
              <input type="text" class="c-month no-key-validation" placeholder="MM" maxlength="2" inputmode="numeric"><span class="date-saperator">/</span>
              <input type="text" class="c-year no-key-validation" placeholder="YYYY" maxlength="4" inputmode="numeric">
              <input errormessagedobminimum="You must be 16 or over to register" class="hidden-date form-control text-box single-line" data-val="true" data-val-required="The DOB field is required." datarequired="Please enter a valid date of birth"
                id="DOB" maxageattribute="Please enter a valid date of birth" maxlength="10" name="DOB" type="date" value="">
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12">
        <div class="form-group">
          <hr>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12">
        <div class="form-group">
          <label>Create your unique sign-in details</label>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-12 col-sm-7 col-lg-5 offset-lg-7">
        <div class="form-group">
          <label>Email address</label>
          <input class="form-control emailApostropheConvert text-box single-line" data-val="true"
            data-val-regexwithoptions="The field  must match the regular expression '^[a-zA-Z\w\.\-\'\u2018\u2019]*@[a-zA-Z0-9][\w\.-]*[a-zA-Z0-9]\.[a-zA-Z][a-zA-Z\.]*[a-zA-Z]$'." data-val-regexwithoptions-flags="i"
            data-val-regexwithoptions-pattern="^[a-zA-Z\w\.\-\'\u2018\u2019]*@[a-zA-Z0-9][\w\.-]*[a-zA-Z0-9]\.[a-zA-Z][a-zA-Z\.]*[a-zA-Z]$" data-val-required="The EmailId field is required."
            datavalidate="Please enter a valid email without special characters (e.g. / ! # $ % *)" dataemailattribute="Please enter a valid email without special characters (e.g. / ! # $ % *)"
            datarequired="Please enter a valid email without special characters (e.g. / ! # $ % *)" emailvalidateattribute="Please enter a valid email without special characters (e.g. / ! # $ % *)" id="EmailId" name="EmailId" type="email" value="">
        </div>
        <div class="password-input-wrap">
          <div class="form-group">
            <label>Create password</label>
            <div class="show-password-wrap">
              <input autocomplete="new-password" class="form-control" data-val="true" data-val-regexwithoptions="The field  must match the regular expression '(?=^.{8,}$)(?=.*\d)(?=.*[a-z])(?=.*[A-Z])(?!.*\s)[0-9a-zA-Z!@#$%^&amp;*()]*$'."
                data-val-regexwithoptions-flags="m" data-val-regexwithoptions-pattern="(?=^.{8,}$)(?=.*\d)(?=.*[a-z])(?=.*[A-Z])(?!.*\s)[0-9a-zA-Z!@#$%^&amp;*()]*$" data-val-required="The Password field is required."
                datarequired="Minimum of 8 characters, at least one uppercase one lowercase and one number" id="password" name="Password" type="password">
              <span class="show-password"></span>
            </div>
          </div>
          <div class="form-group">
            <label>Confirm password</label>
            <div class="show-password-wrap">
              <input autocomplete="new-password" class="form-control" datarequired="Your passwords don't match" equaltopasswordattribute="Your passwords don't match" id="regConfirmPassword" name="ConfirmPassword" type="password">
              <span class="show-password"></span>
            </div>
          </div>
        </div>
      </div>
      <div class="col-12 col-md-6">
        <p class="password-list">Passwords need to include:</p>
        <ul class="password-list">
          <li>Eight or more characters</li>
          <li>At least one upper and lower case character</li>
          <li>At least one number</li>
        </ul>
      </div>
      <div class="col-12 bottom-margin-30px">
        <div class="reg-terms-wrapper">
          <label class="terms-checkbox">
            <input class="reg-checkbox" data-val="true" data-val-required="The TermsAndConditions field is required." id="TermsAndConditions" name="TermsAndConditions" type="checkbox" value="true"><input name="TermsAndConditions" type="hidden"
              value="false">
            <span class="reg-checkmark"></span>
          </label>
          <label class="termsContent">Check this box to accept the <a href="/legal-notices" target="_blank" title="Opens in a new window">Terms of Use</a> and acknowledge that you have read our
            <a href="/legal-notices/privacy-and-cookies" target="_blank" title="Opens in a new window">Privacy Policy</a>.</label>
        </div>
      </div>
    </div>
    <div class="error otp-error-msg"></div>
    <button type="submit" class="btn btn-submit" disabled="">Continue</button>
  </div>
</form>

Text Content

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CREATE YOUR NEW BUPA DIGITAL ACCOUNT

Already used Bupa Touch or Be.Me before? Use those sign-in details here

Make sure all details are exactly as they appear on your Bupa documents.

This lets us link the digital account to you. Where can I find these details?

Please provide personal details as they appear on your Bupa documents
First name

As it appears on your Bupa documents. What do you mean?


Last name
Postcode

As it appears on your Bupa documents. What if I've moved recently?


Date of birth
/ /

--------------------------------------------------------------------------------

Create your unique sign-in details
Email address
Create password

Confirm password


Passwords need to include:

 * Eight or more characters
 * At least one upper and lower case character
 * At least one number

Check this box to accept the Terms of Use and acknowledge that you have read our
Privacy Policy.

Continue


LOOKS LIKE YOU’VE ALREADY GOT A BUPA ACCOUNT

You already have an account that benefits from our latest security features.

Sign in using your Be.Me or Bupa Touch details - the same details will work
here.

Sign in


IF YOU'VE MOVED RECENTLY, YOU STILL NEED TO USE THE ADDRESS DETAILS ON YOUR BUPA
DOCUMENTS.

Once you've successfully created your digital account, please make sure you
update them as soon as possible.



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WHAT DO YOU MEAN?

 * The First Name you enter needs to exactly match your Bupa documents.
 * Only use a shortened version of your name if it's how you would normally
   complete forms e.g. Alexander/Alex/Al etc.
 * Don't use a nickname unless it's likely to be the First Name originally
   given.

Entering your details exactly as originally submitted lets us match them to you.



Close


WHERE CAN I FIND THESE DETAILS?

 * If you have a cover document, your personal details can be found near the
   front
 * If not, check recent Bupa emails, letters or any other communications from
   us.
 * Still unsure? Enter your name in full and try to remember the address you
   originally shared with us.

Entering your details exactly as they appear lets us match them to you.



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