www.secured-site6.com Open in urlscan Pro
69.20.103.146  Public Scan

Form analysis
1 forms found in the DOM

Name: edit_user — POST index.iml

<form name="edit_user" action="index.iml" method="post" onsubmit="return validate_form();" enctype="multipart/form-data">
  <table cellpadding="1" cellspacing="2" border="0">
    <tbody>
      <tr>
        <td colspan="2"><b>Your Contact Information:</b>
          <span class="small-text">(Items marked with <span class="warning">*</span> are required)</span>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="" style="width:150px;">
          <input type="hidden" name="pid" value="2903Fideli">
          <input type="hidden" name="CONTACT_Contact_ID" value="">
          <input type="hidden" name="mdl" value="contacts/contact_form_refresh.mdl">
          <input type="hidden" name="update_msg" value="">
          <input type="hidden" name="update_class" value="">
          <input type="hidden" name="Create_New" value="1">
          <input type="hidden" name="login_mdl" value="contacts/create_my_account.mdl">
          <input type="hidden" name="mdl" value="docLib/products.mdl">
          <input type="hidden" name="update_mdl" value="">
          <span class="warning">*</span>First Name:
        </td>
        <td valign="top">
          <input type="text" name="CONTACT_First_Name" value="" style="width:300px;">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_First_Name, "Please enter a Name.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap=""> <span class="warning">*</span>Last Name: </td>
        <td valign="top">
          <input type="text" name="CONTACT_Last_Name" value="" style="width:300px;">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_Last_Name, "Please enter a Name.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">
          <span class="warning">*</span>E-mail Address:
        </td>
        <td valign="top">
          <input type="text" name="CONTACT_Email" value="" style="width:300px;">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_Email, "Please enter an E-mail address.", 2, "@");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">
          <span class="warning">*</span>Password :
        </td>
        <td valign="top">
          <input type="password" name="CONTACT_Password" value="" style="width:300px;">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_Password, "Please enter a Password.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">Company/Branch:</td>
        <td valign="top">
          <!-- inputs 
  Required: (one or more of the following)
    COMPANY_FIELD_NAME
    BRANCH_FIELD_NAME
    CONTACT_FIELD_NAME    
    SHOW_LABELS    
    SHOW_QUICK_FORM
-->
          <!-- define scripts/data for selecting a contact -->
          <script language="javascript">
            <!--
            var branches = new Array;
            var contacts = new Array;
            var CURRENT_company = null;
            var CURRENT_branch = null;
            var CURRENT_contact = null;

            function add_branch_item(company_id, branch_id, branch_name) {
              branches[branches.length] = new Array(company_id, branch_id, branch_name);
            }

            function add_contact_item(company_id, branch_id, contact_id, name, select_contact) {
              contacts[contacts.length] = new Array(company_id, branch_id, contact_id, name);
              if (select_contact) {
                update_selected_contact(company_id, branch_id, contact_id);
              }
            }
            add_branch_item('51574', '18360', 'BSWH');

            function update_selected_contact(company_id, branch_id, contact_id) {
              if (CURRENT_company != null)
                for (var i = 0; i < CURRENT_company.options.length; i++)
                  if (CURRENT_company.options[i].value == company_id) {
                    CURRENT_company.selectedIndex = i;
                    load_branch(CURRENT_branch, company_id);
                    break;
                  }
              if (CURRENT_branch != null)
                for (var i = 0; i < CURRENT_branch.options.length; i++)
                  if (CURRENT_branch.options[i].value == branch_id) {
                    CURRENT_branch.selectedIndex = i;
                    load_contact(CURRENT_contact, company_id, branch_id);
                    break;
                  }
              if (CURRENT_contact != null)
                for (var i = 0; i < CURRENT_contact.options.length; i++)
                  if (CURRENT_contact.options[i].value == contact_id) {
                    CURRENT_contact.selectedIndex = i;
                    break;
                  }
            }

            function load_contact(contact, company_id, branch_id) {
              if (contact != null) {
                for (i = contact.options.length; i >= 2; i--) contact.options[i] = null;
                i = 2
                for (j = 0; j < contacts.length; j++) {
                  if (contacts[j][0] == company_id && contacts[j][1] == branch_id) {
                    contact.options[i] = new Option(contacts[j][3]);
                    contact.options[i].value = contacts[j][2];
                    i++;
                  }
                }
              }
            }

            function load_branch(branch, company_id) {
              if (branch != null) {
                for (i = branch.options.length; i >= 2; i--) branch.options[i] = null;
                i = 2;
                for (j = 0; j < branches.length; j++) {
                  if (branches[j][0] == company_id) {
                    branch.options[i] = new Option(branches[j][2]);
                    branch.options[i].value = branches[j][1];
                    i++;
                  }
                }
              }
            }

            function fill_company(comp, branch, contact) {
              var company_id = '51574';
              if (comp != null) company_id = comp.options[comp.selectedIndex].value;
              var branch_id = '18360';
              load_branch(branch, company_id);
              load_contact(contact, company_id, branch_id);
            }

            function fill_branch(comp, branch, contact) {
              var company_id = '51574';
              if (comp != null) company_id = comp.options[comp.selectedIndex].value;
              var branch_id = '18360';
              if (branch != null) branch_id = branch.options[branch.selectedIndex].value;
              load_contact(contact, company_id, branch_id);
            }

            function start_new_contact(comp, branch, contact, pos) {
              CURRENT_company = comp;
              CURRENT_branch = branch;
              CURRENT_contact = contact;
              if (contact != null) contact.selectedIndex = 0;
              var total_x = pos.offsetLeft;
              var total_y = pos.offsetTop;
              var parentEl = pos.offsetParent;
              while (parentEl != null) {
                total_x += parentEl.offsetLeft;
                total_y += parentEl.offsetTop;
                parentEl = parentEl.offsetParent;
              }
              if (total_y < document.body.scrollTop) total_y = document.body.scrollTop + 100;
              obj = document.getElementById("ADD_CONTACT");
              obj.style.visibility = 'visible';
              obj.style.display = 'block';
              obj.style.left = total_x + 10;
              obj.style.top = total_y + 10;
              var header = '';
              if (CURRENT_company.selectedIndex > 1 || CURRENT_branch.selectedIndex > 1) {
                header = "New contact for: "
                if (CURRENT_company.selectedIndex > 1) header = header + CURRENT_company.options[CURRENT_company.selectedIndex].text + ": "
                if (CURRENT_branch.selectedIndex > 1) header = header + CURRENT_branch.options[CURRENT_branch.selectedIndex].text;
              } else {
                header = 'This contact will not be associated with a company';
              }
              document.getElementById("ADD_CONTACT_HEADER").innerHTML = header;
            }

            function create_contact(first_name, last_name, email, div_id) {
              if (email.value.indexOf("@") < 1) {
                email.className = "required-input";
                alert("Please Enter an E-mail Address");
                email.focus();
              } else {
                if (CURRENT_company != null) company_id = CURRENT_company.options[CURRENT_company.selectedIndex].value;
                if (CURRENT_branch != null) branch_id = CURRENT_branch.options[CURRENT_branch.selectedIndex].value;
                var f_name = first_name.value;
                first_name.value = "";
                var l_name = last_name.value;
                last_name.value = "";
                var e_mail = email.value;
                email.value = "";
                hide('ADD_CONTACT');
                frames['LOADIN_FRAME'].location.href = "loadin.iml?mdl=contacts/quick_create.mdl&update_selects=1&CONTACT_Company_ID=" + company_id + "&CONTACT_Branch_ID=" + branch_id + "&CONTACT_First_Name=" + escape(f_name) +
                  "&CONTACT_Last_Name=" + escape(l_name) + "&CONTACT_Email=" + escape(e_mail);
              }
            }
            //
            -->
          </script>
          <!-- admin -->
          <!-- DEF_SELECT_CONTACT_SCRIPT -->
          <table cellpadding="0" cellspacing="0">
            <tbody>
              <tr>
                <td valign="top" style="padding-bottom:5px;">
                  <input type="hidden" name="CONTACT_Company_ID" value="51574"> Baylor Scott &amp; White Health<br>
                </td>
              </tr>
              <tr>
                <td valign="top" style="padding-bottom:5px;">
                  <input type="hidden" name="CONTACT_Branch_ID" value="18360"> BSWH<br>
                </td>
              </tr>
            </tbody>
          </table>
        </td>
      </tr>
      <tr>
        <td style="text-align: right;">Location:</td>
        <td>United States</td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap=""><span class="warning">*</span>Address:</td>
        <td>
          <input type="text" style="width:300px;" name="ADDR_AddressLine1" value="">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.ADDR_AddressLine1, "Please enter your address.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">&nbsp;</td>
        <td>
          <input type="text" style="width:300px;" name="ADDR_AddressLine2" value="">
        </td>
      </tr>
      <tr>
        <td align="right" valign="top"><span class="warning">*</span>City:</td>
        <td><input type="text" name="ADDR_City" value="" style="width:300px">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.ADDR_City, "Please enter your city.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top"><span class="warning">*</span>State:</td>
        <td><input type="text" name="ADDR_State" value="" style="width:300px">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.ADDR_State, "Please enter your state.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top"><span class="warning">*</span>Zip:</td>
        <td><input type="text" name="ADDR_PostalCode" value="" style="width:300px">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.ADDR_PostalCode, "Please enter your Zip code.", 2, "");
          </script>
        </td>
      </tr>
      <tr style="display: none;">
        <td align="right" valign="top">Country:</td>
        <td><input type="text" name="ADDR_Country" value="United States" style="width:300px">
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap=""><span class="warning">*</span>Title:</td>
        <td valign="top">
          <input type="text" style="width:300px;" name="CONTACT_Position" value="">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_Position, "Please enter your title.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">
          <span class="warning">*</span>Phone:
        </td>
        <td valign="top" nowrap="">
          <input type="text" name="CONTACT_Phone" value="" style="width:300px;" onchange="phone_filter(this,'(',') ','-',' x');">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_Phone, "Please enter a phone number.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap=""> Extension: </td>
        <td valign="top" nowrap="">
          <input type="text" style="width:300px;" name="CONTACT_PhoneExt" value="">
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">
          <span class="warning">*</span>Fax:
        </td>
        <td valign="top">
          <input type="text" name="CONTACT_Fax" value="" style="width:300px;" onchange="phone_filter(this,'(',') ','-',' x');">
          <script language="javascript">
            add_required_field("ACCOUNT", document.edit_user.CONTACT_Fax, "Please enter a fax number.", 2, "");
          </script>
        </td>
      </tr>
      <tr>
        <td align="right" valign="top" nowrap="">Email Format:</td>
        <td valign="top">
          <input type="radio" name="CONTACT_HTML_Emails" value="1" checked=""> HTML &nbsp;&nbsp; <input type="radio" name="CONTACT_HTML_Emails" value="0"> Plain Text
        </td>
      </tr>
      <tr>
        <td colspan="2" align="center">
          <input type="submit" value="Create Account" class="medium green button">
        </td>
      </tr>
    </tbody>
  </table>
</form>

Text Content

 

Return to the Baylor Brand Center

 


  ORDER YOUR PRINTING

Create an Account
 
(Click the triangle above to expand this panel.)

Your Contact Information: (Items marked with * are required) *First Name: *Last
Name: *E-mail Address: *Password : Company/Branch:

Baylor Scott & White Health
BSWH


Location:United States *Address:   *City: *State: *Zip: Country: *Title: *Phone:
Extension: *Fax: Email Format: HTML    Plain Text

    


Ways to Continue:
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