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formsveavaccinse.kund.westart.se Open in urlscan Pro
217.25.34.119  Public Scan

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URL: https://formsveavaccinse.kund.westart.se/
Submission: On June 20 via api from US — Scanned from SE

Form analysis 1 forms found in the DOM

POST 

<form method="post" action="">
  <div class="input-holder">
    <label>Personnummer (12 siffror)</label> <span class="red">*</span>
    <input class="disable-autofill" type="number" maxlength="12" name="ssn" placeholder="XXXXXXXXXXXX" value="" oninput="javascript: if (this.value.length > this.maxLength) this.value = this.value.slice(0, this.maxLength);">
  </div>
  <div class="input-holder">
    <label>Förnamn</label> <span class="red">*</span>
    <input class="disable-autofill" type="text" name="first_name" value="">
  </div>
  <div class="input-holder">
    <label>Efternamn</label> <span class="red">*</span>
    <input class="disable-autofill" type="text" name="last_name" value="">
  </div>
  <div class="input-holder">
    <label>Adress</label>
    <input class="disable-autofill" type="text" name="address" value="">
  </div>
  <div class="input-holder">
    <label>Postnummer</label>
    <input class="disable-autofill" type="number" name="zip" value="" maxlength="5" oninput="javascript: if (this.value.length > this.maxLength) this.value = this.value.slice(0, this.maxLength);">
  </div>
  <div class="input-holder">
    <label>Stad</label>
    <input class="disable-autofill" type="text" name="city" value="">
  </div>
  <div class="input-holder">
    <label>E-post</label>
    <input class="disable-autofill" type="email" name="email" value="">
  </div>
  <div class="input-holder">
    <label>Mobiltelefon</label> <span class="red">*</span>
    <input class="disable-autofill" type="tel" name="mobile_phone" value="">
  </div>
  <div class="input-holder">
    <label>Vikt, endast barn (kg)</label>
    <input type="number" name="weight" value="" maxlength="3" oninput="javascript: if (this.value.length > this.maxLength) this.value = this.value.slice(0, this.maxLength);">
  </div>
  <div class="input-holder">
    <label>Resmål</label>
    <input class="disable-autofill" type="text" name="country" value="">
  </div>
  <div class="input-holder">
    <label>Avresedatum</label>
    <input type="date" name="departure_date" class="noselect" value="" onkeypress="return false">
  </div>
  <div class="input-holder">
    <label>Resans längd</label>
    <input class="disable-autofill" type="text" name="visit_length" value="">
  </div>
  <div class="input-holder">
    <label>Syfte med resan</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 73.5938px; width: 650px; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="info" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Tidigare reagerat negativt på vaccination <input type="checkbox" name="earlier_reaction" id="earlier_reaction" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Beskrivning</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="earlier_reaction_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Feber/pågående infektion <input type="checkbox" name="infection" id="infection" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vad?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="infection_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Överkänslig/allergisk <input type="checkbox" name="allergy" id="allergy" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vad?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="allergy_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Vaccination de senaste 2-4 veckorna <input type="checkbox" name="vaccination" id="vaccination" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vilka?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="vaccination_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Regelbundet läkemedel <input type="checkbox" name="medicine" id="medicine" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vad?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="medicine_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Kronisk sjukdom <input type="checkbox" name="disease" id="disease" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vad?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="disease_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Pågående behandling <input type="checkbox" name="treatment" id="treatment" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vilken?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="treatment_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Blodförtunnande medicin <input type="checkbox" name="blood_medicine" id="blood_medicine" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vilken?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="blood_medicine_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Depression/psykisk sjukdom <input type="checkbox" name="psychic_disease" id="psychic_disease" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Vilken?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="psychic_disease_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="input-holder">
    <label class="container">Gravid/avser att bli gravid/ammar <input type="checkbox" name="pregnant" id="pregnant" class="condition" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder hidden">
    <label>Månad?</label>
    <textarea style="resize: none; overflow-y: hidden; position: absolute; top: 0px; left: -9999px; height: 0px; width: 100%; line-height: 30px; text-decoration: none solid rgb(0, 0, 0); letter-spacing: 0px;" tabindex="-1"></textarea><textarea
      name="pregnant_desc" style="resize: none; overflow-y: hidden;"></textarea>
  </div>
  <div class="divider"></div>
  <div class="input-holder">
    <label class="container"> Jag godkänner att Svea Vaccin skickar information om vacciner till mig via e-post. <input type="checkbox" name="contact_ok" id="contact_ok" value="1" checked="">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="divider"></div>
  <div class="input-holder">
    <label class="container">Jag har tagit del av och godkänner Svea Vaccins <a href="https://sveavaccin.se/integritetspolicy/" target="_blank">Integritetspolicy för kunduppgifter</a>. <span class="red">*</span>
      <input type="checkbox" name="privacy_policy_ok" id="privacy_policy_ok" value="1">
      <span class="checkmark"></span>
    </label>
  </div>
  <div class="input-holder submit">
    <input type="hidden" name="post" value="1">
    <input type="hidden" name="csrf_token" value="6673e25779d4f">
    <input type="submit" value="Skicka hälsodeklaration">
  </div>
</form>

Text Content

HÄLSODEKLARATION


* Obligatoriska fält
Svenska | English
Personnummer (12 siffror) *
Förnamn *
Efternamn *
Adress
Postnummer
Stad
E-post
Mobiltelefon *
Vikt, endast barn (kg)
Resmål
Avresedatum
Resans längd
Syfte med resan
Tidigare reagerat negativt på vaccination
Beskrivning
Feber/pågående infektion
Vad?
Överkänslig/allergisk
Vad?
Vaccination de senaste 2-4 veckorna
Vilka?
Regelbundet läkemedel
Vad?
Kronisk sjukdom
Vad?
Pågående behandling
Vilken?
Blodförtunnande medicin
Vilken?
Depression/psykisk sjukdom
Vilken?
Gravid/avser att bli gravid/ammar
Månad?

Jag godkänner att Svea Vaccin skickar information om vacciner till mig via
e-post.

Jag har tagit del av och godkänner Svea Vaccins Integritetspolicy för
kunduppgifter. *