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dev-feedback.romtech.com Open in urlscan Pro
20.49.104.48  Public Scan

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URL: https://dev-feedback.romtech.com/
Submission: On August 06 via automatic, source certstream-suspicious — Scanned from US

Form analysis 1 forms found in the DOM

POST 

<form method="post">
  <span class="d-flex justify-content-center mb-5" style="height: 110px; overflow: hidden;">
    <img src="/images/ROM Logo Transparent.png" alt="ROMTech logo" style="max-width: 100%; min-height: 300px; margin-top: -95px;">
  </span>
  <span class="d-flex justify-content-center">
    <h1 style="color: #3E9FC0; font-weight: bold;">Feedback Form</h1>
  </span>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_TicketTypeId">Type: </label>
    <select class="form-control form-select " data-val="true" data-val-maxlength="The field TicketTypeId must be a string or array type with a maximum length of '4'." data-val-maxlength-max="4" id="Ticket_TicketTypeId" name="Ticket.TicketTypeId">
      <option value="FBK">Feedback</option>
      <option value="IDA">Idea</option>
      <option value="ISS">Issue</option>
    </select>
  </div>
  <div class="form-group input-group-lg mt-2" id="ticket_rating" style="display: block;">
    <label class="control-label" for="Ticket_TicketRating">Rating: </label>
    <div id="rating_stars" class="d-flex justify-content-center" style="color: #0899B7;">
      <span class="material-symbols-outlined user-select-none rating-star" data-rating="1">star</span><span class="material-symbols-outlined user-select-none rating-star" data-rating="2">star</span><span
        class="material-symbols-outlined user-select-none rating-star" data-rating="3">star</span><span class="material-symbols-outlined user-select-none rating-star" data-rating="4">star</span><span
        class="material-symbols-outlined user-select-none rating-star" data-rating="5">star</span>
    </div>
    <input class="form-control " hidden="" type="number" id="Ticket_TicketRating" name="Ticket.TicketRating" value=""><input name="__Invariant" type="hidden" value="Ticket.TicketRating">
    <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.TicketRating" data-valmsg-replace="true"></span>
  </div>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_selectedComponents">Components: </label>
    <select class="form-control form-select " id="Ticket_selectedComponents" multiple="multiple" name="Ticket.selectedComponents">
      <option value="1">Blood Pressure Monitor</option>
      <option value="2">Cardiac App</option>
      <option value="3">CardiacConnect</option>
      <option value="4">Charging Hub</option>
      <option value="5">Clinician Portal</option>
      <option value="6">ECG Patch</option>
      <option value="7">Observer Dashboard</option>
      <option value="8">Ortho App</option>
      <option value="9">PortableConnect</option>
      <option value="10">SpO2 sensor</option>
    </select>
    <small style="font-weight: normal;">Hold down the Ctrl (windows) / Command (Mac) button to select multiple options.</small>
  </div>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_selectedCategories">Categories: </label>
    <select class="form-control form-select " id="Ticket_selectedCategories" multiple="multiple" name="Ticket.selectedCategories">
      <option value="1">Beneficiary Complaint</option>
      <option value="2">Billing Request</option>
      <option value="3">Feedback</option>
      <option value="4">Knowledge &amp; Education</option>
      <option value="5">Mechanical/Electrical Issue</option>
      <option value="6">Negative</option>
      <option value="7">Non-Customer Service Issue</option>
      <option value="8">Physician Request</option>
      <option value="9">Positive</option>
      <option value="10">Remote Onboarding</option>
      <option value="11">Software Issue</option>
      <option value="14">CRS</option>
    </select>
    <small style="font-weight: normal;">Hold down the Ctrl (windows) / Command (Mac) button to select multiple options.</small>
  </div>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_SubmittedBy">Email Address*: </label>
    <input class="form-control " required="True" type="text" data-val="true" data-val-maxlength="The field Submitted by must be a string or array type with a maximum length of '64'." data-val-maxlength-max="64" id="Ticket_SubmittedBy" maxlength="64"
      name="Ticket.SubmittedBy" value="">
    <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.SubmittedBy" data-valmsg-replace="true"></span>
  </div>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_SubmittedOnBehalfOf">Submitted on Behalf of: </label>
    <input class="form-control " type="text" data-val="true" data-val-maxlength="The field Submitted on behalf of must be a string or array type with a maximum length of '64'." data-val-maxlength-max="64" id="Ticket_SubmittedOnBehalfOf"
      maxlength="64" name="Ticket.SubmittedOnBehalfOf" value="">
    <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.SubmittedOnBehalfOf" data-valmsg-replace="true"></span>
  </div>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_TicketTitle">Title*: </label>
    <input class="form-control " required="True" type="text" data-val="true" data-val-maxlength="The field Title must be a string or array type with a maximum length of '128'." data-val-maxlength-max="128" id="Ticket_TicketTitle" maxlength="128"
      name="Ticket.TicketTitle" value="">
    <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.TicketTitle" data-valmsg-replace="true"></span>
  </div>
  <div class="form-group input-group-lg mt-2">
    <label class="control-label" for="Ticket_TicketDetail">Message*: </label>
    <textarea class="form-control " style="min-height: 300px;" required="True" id="Ticket_TicketDetail" name="Ticket.TicketDetail"></textarea>
    <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.TicketDetail" data-valmsg-replace="true"></span>
  </div>
  <div id="patient_information" style="display: none;">
    <div class="form-group input-group-lg mt-2">
      <label class="control-label" for="Ticket_Surgeon">Surgeon: </label>
      <input class="form-control " type="text" data-val="true" data-val-maxlength="The field Surgeon must be a string or array type with a maximum length of '64'." data-val-maxlength-max="64" id="Ticket_Surgeon" maxlength="64" name="Ticket.Surgeon"
        value="">
      <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.Surgeon" data-valmsg-replace="true"></span>
    </div>
    <div class="form-group input-group-lg mt-2">
      <label class="control-label" for="Ticket_PatientIds">Patient ID: </label>
      <input class="form-control " type="text" data-val="true" data-val-maxlength="The field Patient IDs must be a string or array type with a maximum length of '256'." data-val-maxlength-max="256" id="Ticket_PatientIds" maxlength="256"
        name="Ticket.PatientIds" value="">
      <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.PatientIds" data-valmsg-replace="true"></span>
    </div>
    <div class="form-group input-group-lg mt-2">
      <label class="control-label" for="Ticket_SessionDate">Session Date &amp; Time: </label>
      <input class="form-control " type="datetime-local" id="Ticket_SessionDate" name="Ticket.SessionDate" value=""><input name="__Invariant" type="hidden" value="">
      <span class="text-danger field-validation-valid" data-valmsg-for="Ticket.SessionDate" data-valmsg-replace="true"></span>
    </div>
  </div>
  <div class="form-group input-group-lg mt-2 d-flex justify-content-center mt-3">
    <input type="submit" value="Submit" class="btn ps-5 pe-5" style="background-color: #0899B7; color: white; border-radius: 30px;">
  </div>
  <input name="__RequestVerificationToken" type="hidden" value="CfDJ8LWlAZNeZcJOlFCfEtTXWMY8-UnCqjb0sK7t5JTH5YqSYKdc81AgZnz-jLZPN_Xy5uqn2KmgumuxSfGMDaouu5hMzndoU8gkpCBhGaFWPzL18Sw7q-K5Htm5xM31lGnnyZwpUjw7wrLoTv3qnI5opJg">
</form>

Text Content

FEEDBACK FORM

Type: Feedback Idea Issue
Rating:
starstarstarstarstar
Components: Blood Pressure Monitor Cardiac App CardiacConnect Charging Hub
Clinician Portal ECG Patch Observer Dashboard Ortho App PortableConnect SpO2
sensor Hold down the Ctrl (windows) / Command (Mac) button to select multiple
options.
Categories: Beneficiary Complaint Billing Request Feedback Knowledge & Education
Mechanical/Electrical Issue Negative Non-Customer Service Issue Physician
Request Positive Remote Onboarding Software Issue CRS Hold down the Ctrl
(windows) / Command (Mac) button to select multiple options.
Email Address*:
Submitted on Behalf of:
Title*:
Message*:
Surgeon:
Patient ID:
Session Date & Time: