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54.159.207.63  Public Scan

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Submitted URL: http://www.invitae.com/pio/requisition-billing
Effective URL: https://www.invitae.com/us/patients/requisition-billing
Submission: On July 07 via manual from CO — Scanned from DE

Form analysis 1 forms found in the DOM

Name: requisition-billing-form — #

<form action="#" data-testid="requisition-billing-form" name="requisition-billing-form">
  <div class="row">
    <div class="c0233 col-md-6"><label class="c0234" for="rq">ORDER ID</label>
      <div class="c0235"><span>RQ</span><input name="rq" class="c0232" data-testid="input-rq" id="rq" type="text" value=""></div>
    </div>
    <div class="c0233 col-md-6 col-sm-12"><label class="c0234" for="dob">PATIENT DATE OF BIRTH</label>
      <div class="DayPickerInput">
        <div><input type="text" placeholder="MM/DD/YYYY" class="c0232" data-testid="input-dob" name="dob" value=""><span role="button" tabindex="0"></span></div>
      </div>
    </div>
  </div>
  <div class="row">
    <div class="col-md-6 col-sm-12"><button data-testid="submit-requisition-billing-form" disabled="" type="submit" class="btn-teal btn btn-lg btn-default btn-block">Continue</button></div>
  </div>
</form>

Text Content

You need to enable JavaScript to run this app.
Billing and payment details
Confirm


VIEW YOUR BILLING AND PAYMENT DETAILS


ORDER DETAILS

Enter an Order ID and the patient's date of birth to see the billing details.

ORDER ID
RQ
PATIENT DATE OF BIRTH

Continue

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