crm.bestnotes.com Open in urlscan Pro
34.173.124.86  Public Scan

Form analysis
2 forms found in the DOM

Name: LOGIN — POST

<form id="LOGIN" name="LOGIN" method="post" style="margin:0px;">
  <input type="hidden" name="csrf_token" value="EpbhFS7z7bFXw27euJaUwnYeXGCBzAFZqp94_8JQ74Y">
  <table style="width: 100%; margin-top: 5px;">
    <tbody>
      <tr>
        <td class="labelcell">
          <label for="LUID">User ID (email):</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" type="text" style="width: 238px;" id="LUID" name="LUID" value="" onchange="trimFieldValue(this)">
        </td>
      </tr>
      <tr>
        <td class="labelcell">
          <label for="LPWD">Password:</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" autocomplete="off" type="password" style="width: 238px;" id="LPWD" name="LPWD">
        </td>
      </tr>
      <tr>
        <td colspan="2" style="padding-top: 20px;" align="center">
          <input class="button" type="submit" value="Log In" style="width: 80px;" onclick="auth()">
          <br>
          <br>
          <a href="" onclick="forgot(); return false;" title="Click to reset your password">Forgot your password?</a><br>
          <div id="errormsg" align="center" style="color: red; font-weight: bold;"> &nbsp; </div>
        </td>
      </tr>
    </tbody>
  </table>
  <input type="hidden" name="NPW" id="NPW" value="">
</form>

Name: NEWAPPLICANT — POST

<form id="NEWAPPLICANT" name="NEWAPPLICANT" method="POST">
  <input type="hidden" name="csrf_token" value="EpbhFS7z7bFXw27euJaUwnYeXGCBzAFZqp94_8JQ74Y">
  <table style="width: 100%; margin-top: 5px;">
    <tbody>
      <tr>
        <td class="labelcell" style="vertical-align: top;">
          <label for="FNAME">Your First Name:</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" type="text" style="width: 200px;" id="FNAME" name="FNAME" value="" onchange="trimFieldValue(this)">
        </td>
      </tr>
      <tr>
        <td class="labelcell" style="vertical-align: top;">
          <label for="LNAME">Last Name:</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" type="text" style="width: 200px;" id="LNAME" name="LNAME" value="" onchange="trimFieldValue(this)">
        </td>
      </tr>
      <tr>
        <td class="labelcell">
          <label for="USERID">User ID (email):</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" type="text" style="width: 200px;" id="USERID" name="USERID" value="" onchange="trimFieldValue(this)">
        </td>
      </tr>
      <tr>
        <td class="labelcell" style="padding-bottom: 10px;">
          <label for="CONFIRMUSER">Confirm:</label>
        </td>
        <td class="contentcell" style="padding-bottom: 10px;">
          <input class="grayborder" type="text" style="width: 200px;" autocomplete="off" id="CONFIRMUSER" name="CONFIRMUSER" value="" onchange="trimFieldValue(this)">
        </td>
      </tr>
      <tr>
        <td class="labelcell">
          <label for="PASSWORD">Password:</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" autocomplete="off" type="password" style="width: 200px;" id="PASSWORD" name="PASSWORD" value="">
          <img alt="reply button" style="position:absolute;margin:5px;display:inline-block;"
            onclick="alert('Password needs to be at least 8 characters long.&nbsp;&nbsp;Password must contain uppercase, lowercase letters, numbers and special characters.');"
            title="Password needs to be at least 8 characters long.&nbsp;&nbsp;Password must contain uppercase, lowercase letters, numbers and special characters." src="/crmbeta/images/help.png">
        </td>
      </tr>
      <tr>
        <td class="labelcell">
          <label for="CONFIRMPASSWORD">Confirm:</label>
        </td>
        <td class="contentcell">
          <input class="grayborder" autocomplete="off" type="password" style="width: 200px;" id="CONFIRMPASSWORD" name="CONFIRMPASSWORD" value="">
        </td>
      </tr>
      <!--<tr>
					<td colspan="2" align="right" style="padding-top: 10px;">Security Question: <input type="text" name="QUESTION" style="width: 235px;" value=""></td>
					</tr>
					<tr>
					<td class="labelcell">Answer:</td>
					<td class="contentcell"><input type="text" name="ANSWER" style="width: 238px;"></td>
					</tr>-->
      <tr>
        <td colspan="2" style="padding-top: 20px;" align="center">
          <input id="createPortalAccount" class="button" type="button" value="Create Account" onclick="submitNew(); return false;">
          <input id="termsCondsChecked" type="hidden" name="termsCondsChecked" value="0">
          <input id="termsCondsVersion" type="hidden" name="termsCondsVersion" value="V1.0">
        </td>
      </tr>
    </tbody>
  </table>
  <div id="termsCondsPopup">
    <div class="termsCondsContent">
      <iframe id="termsCondsContentIFrame" src="/terms/terms/V1.0.html" frameborder="0"></iframe>
    </div>
    <div class="termsCondsCheck">
      <input type="checkbox" name="termsCondsAgree" id="termsCondsAgree" style="vertical-align: middle"> I agree to the terms of use <input id="cancelPortalAccount" class="button" type="button" value="Cancel"
        onclick="cancelTermsDialogBox('signup');">
      <input id="createPortalAccountTerms" class="button termsFloatRight" type="button" value="Continue" onclick="submitNew(); return false;">
    </div>
  </div>
  <style>
    #termsCondsContentIFrame {
      margin: 0;
      width: 100%;
      height: 100%;
    }

    #termsCondsPopup {
      display: none;
      margin: 0 auto;
    }

    .termsCondsContent {
      height: 520px !important;
    }

    .termsCondsCheck {
      border-top: 1px solid gray;
      margin-top: 5px;
      padding: 10px 0;
    }

    #cancelPortalAccount {
      float: right;
      margin-left: 10px;
    }

    .termsFloatRight {
      float: right;
    }
  </style>
  <script>
    // function to close the Terms popup
    function cancelTermsDialogBox(action) {
      jQuery('#termsCondsPopup').dialog('close');
      jQuery('#termsCondsPopup').dialog('destroy');
      jQuery('#createPortalAccount').removeAttr('disabled');
      // if FORM action is create account, then on cancel make checkbox and button disabled so that user can again see popup with disable button
      if (action == 'signup') {
        jQuery('#termsCondsAgree').prop('checked', false);
      }
    }
    // function to open the Terms popup
    function openTermsDialogBox() {
      jQuery('#termsCondsPopup').dialog('destroy');
      var termsCondsVersion = jQuery('#termsCondsVersion').val();
      var termsCondsCreatedDate = jQuery('#termsCondsCreatedDate').val();
      jQuery('#termsCondsPopup').dialog({
        autoOpen: false,
        minHeight: 0,
        width: 780,
        modal: true,
        resizable: false,
        title: 'Patient Portal Terms Of Use - ' + termsCondsVersion + ' - Last updated: ' + termsCondsCreatedDate,
        position: ['center', 10],
        open: function() {
          jQuery(this).closest('.ui-dialog').find('.ui-dialog-titlebar-close').removeClass('ui-dialog-titlebar-close').html('')
        },
        close: function(a, ui) {
          jQuery('#termsCondsPopup').dialog('destroy');
        }
      });
      jQuery('#termsCondsPopup').dialog('open');
    }
    // if user click on submit button, validate if terms agree checkbox checked
    // if yes, post the form data and save to DB
    function submitTermsConds() {
      if (jQuery('#termsCondsPopup').css('display') == 'block') {
        if (!jQuery('#termsCondsAgree').is(':checked')) {
          alert('Please indicate that you have read and agree to the Terms of Use');
          return false;
        }
      }
      var postvars = Form.serialize('userTermsCondsForm');
      postvars += "&csrf_token=" + csrf_token;
      var postData = {
        url: 'update_fields.php',
        type: 'POST',
        async: false,
        data: postvars,
        dataType: "json",
        success: function(response) {
          if (response.error) {
            alert(response.error);
            return;
          }
          if (response && response.redirectToMainMenu) {
            if (response.alert) {
              alert(response.alert);
            }
            document.location = rooturl + "menu";
            success = false;
            preventConnectionErrorPopup = true;
          }
          document.location = document.location;
        }
      };
      jQuery.ajax(postData);
      return success;
    }
  </script>
</form>

Text Content

 



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Portal


LOGIN

Login to existing account: Create a new account:

User ID (email): Password:

Forgot your password?

 

Your First Name: Last Name: User ID (email): Confirm: Password: Confirm:

I agree to the terms of use



By using the Portal you agree to the Terms of Use.
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