mindunit.azfamtech.com Open in urlscan Pro
103.143.76.152  Public Scan

Form analysis
2 forms found in the DOM

POST

<form action="" method="POST">
  <div class="f-form-element">
    <label for="f-name">Full Name</label>
    <input name="f-name" type="text" id="f-name" placeholder="Enter Your Name" pattern="^[a-zA-Z]{4,}(?: [a-zA-Z]+){0,2}$" required="">
  </div>
  <div class="f-form-element">
    <label for="f-email">Email</label>
    <input name="f-mail" type="text" id="f-email" placeholder="Enter Your Email" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,4}$" required="">
  </div>
  <div class="f-form-element">
    <label>Message</label>
    <textarea style="border-radius: 5px; resize: none;overflow-y: scroll;height:100px;" name="f-message" id="" cols="30" rows="10" placeholder="Max 200 Digits" required=""></textarea>
  </div>
  <div class="f-form-element">
    <button name="btn" style="background-color: #5a92b8;">Submit</button>
  </div>
</form>

POST

<form action="" method="POST">
  <div class="inputBox">
    <input type="text" name="c-fname" placeholder="First Name" pattern="^([A-Za-z]+[,.]?[ ]?|[A-Za-z]+['-]?)+$" required="">
    <input type="text" name="c-lname" placeholder="Last Name" pattern="^([A-Za-z]+[,.]?[ ]?|[A-Za-z]+['-]?)+$" required="">
  </div>
  <div class="inputBox">
    <input type="email" name="c-mail" placeholder="Email" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,4}$" required="">
    <input type="text" name="c-phone" placeholder="Phone Ex: 03*********" pattern="[03][0-9]{11-18}" required="">
  </div> <br>
  <textarea style="border-radius: 5px;" name="c-message" id="" cols="30" rows="10" placeholder="Max 200 Digits" required=""></textarea>
  <input type="submit" name="btninsert" value="Submit" class="button">
</form>

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What personal information do I need to bring with me to the hospital?

Please bring the following items, as appropriate: medical insurance card,
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