payments.regionalradiologygroup.com Open in urlscan Pro
35.194.44.215  Public Scan

Form analysis
1 forms found in the DOM

POST

<form class="cart" action="" method="post" enctype="multipart/form-data">
  <div class="nyp" data-price="0" data-minimum-error="Please enter at least %%MINIMUM%%." data-hide-minimum="" data-hide-minimum-error="Please enter a higher amount." data-max-price=""
    data-maximum-error="Please enter less than or equal to %%MAXIMUM%%." data-min-price="0">
    <div class="woocommerce-nyp-message woocommerce-error" style="display: none;"></div>
    <label for="nyp">
      <span class="nyp-field-label"> Amount: ( $ ) </span>
    </label>
    <input id="nyp" name="nyp" type="text" value="" title="Amount: ( $ )" class="input-text amount nyp-input text">
  </div>
  <div class="wc-pao-addon-container  wc-pao-addon wc-pao-addon-bill-data" data-product-name="Bill Payment">
    <h3 class="wc-pao-addon-heading">Bill Data</h3>
    <div class="clear"></div>
  </div>
  <div class="wc-pao-addon-container wc-pao-required-addon wc-pao-addon wc-pao-addon-account-number" data-product-name="Bill Payment">
    <label class="wc-pao-addon-name" data-addon-name="Account Number" data-has-per-person-pricing="" data-has-per-block-pricing="">Account Number <em class="required" title="Required field">*</em>&nbsp;</label>
    <p class="form-row form-row-wide wc-pao-addon-wrap wc-pao-addon-9-account-number-1">
      <textarea type="text" class="input-text wc-pao-addon-field wc-pao-addon-custom-textarea" data-raw-price="" data-price="" data-price-type="quantity_based" name="addon-9-account-number-1" rows="4" cols="20" required=""></textarea>
    </p>
    <div class="clear"></div>
  </div>
  <div class="wc-pao-addon-container wc-pao-required-addon wc-pao-addon wc-pao-addon-last-name" data-product-name="Bill Payment">
    <label class="wc-pao-addon-name" data-addon-name="Last Name" data-has-per-person-pricing="" data-has-per-block-pricing="">Last Name <em class="required" title="Required field">*</em>&nbsp;</label>
    <p class="form-row form-row-wide wc-pao-addon-wrap wc-pao-addon-9-last-name-2">
      <textarea type="text" class="input-text wc-pao-addon-field wc-pao-addon-custom-textarea" data-raw-price="" data-price="" data-price-type="quantity_based" name="addon-9-last-name-2" rows="4" cols="20" required=""></textarea>
    </p>
    <div class="clear"></div>
  </div>
  <div id="product-addons-total" data-show-sub-total="1" data-type="simple" data-tax-mode="excl" data-tax-display-mode="excl" data-price="" data-raw-price="" data-product-id="9">
    <div class="product-addon-totals">
      <ul>
        <li>
          <div class="wc-pao-col1"><strong>1x Bill Payment</strong></div>
          <div class="wc-pao-col2"><strong>$0.00</strong></div>
        </li>
        <li class="wc-pao-subtotal-line">
          <p class="price">Subtotal <span class="amount">$0.00</span></p>
        </li>
      </ul>
    </div>
  </div>
  <div class="quantity hidden buttons_added"><input type="button" value="-" class="minus">
    <input type="text" id="quantity_63e63a699f7b1" class="qty" name="quantity" value="1">
    <input type="button" value="+" class="plus">
  </div>
  <button type="submit" name="add-to-cart" value="9" class="single_add_to_cart_button button alt">Pay Bill</button>
</form>

Text Content

 * Make a Payment




 * Make a Payment



Regional Radiology Group now accepts online payments for bills.
Make a secure payment online.




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BILL PAYMENT




Amount: ( $ )


BILL DATA


Account Number * 




Last Name * 




 * 1x Bill Payment
   $0.00

 * Subtotal $0.00


Pay Bill
Category: Uncategorized
 * 
 * 
 * 
 * 

 * Description


DESCRIPTION

[dt_gap height=”100″ /]






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