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POST /recalls/x11ndMPWmymdXa86NuSUGA

<form action="/recalls/x11ndMPWmymdXa86NuSUGA" accept-charset="UTF-8" method="post">
  <div class="field">
    <label>Your Last Name</label>
    <input id="last_name" tabindex="1" type="text" autocomplete="off" autocorrect="off" name="last_name" placeholder="Last Name">
  </div>
  <div class="field">
    <label> Your Date of Birth</label>
    <div class="dob">
      <div class="cell">
        <input id="dob_day" name="date_of_birth[day]" tabindex="2" class="auto-advance" type="number" min="1" max="31" inputmode="numeric" pattern="[0-9]*" placeholder="DD" autocomplete="off" autocorrect="off">
      </div>
      <div class="cell">
        <input id="dob_month" name="date_of_birth[month]" tabindex="3" class="auto-advance" type="number" min="1" max="12" inputmode="numeric" pattern="[0-9]*" placeholder="MM" autocomplete="off" autocorrect="off">
      </div>
      <div class="cell">
        <input id="dob_year" name="date_of_birth[year]" tabindex="4" type="number" min="0" inputmode="numeric" pattern="[0-9]*" placeholder="YYYY" autocomplete="off" autocorrect="off">
      </div>
    </div>
  </div>
  <script type="text/javascript">
    // Focus next field when the user hits the 'Go' button on iOS keyboard.
    var nameInput = document.getElementById("last_name");
    nameInput.addEventListener("keypress", function(e) {
      var keycode = (event.keyCode ? event.keyCode : event.which);
      if (keycode == '13') {
        document.getElementById("dob_day").focus();
        e.preventDefault();
      }
    });
    // Advance DOB fields automatically after two digits
    var autoAdvanceInputs = document.getElementsByClassName("auto-advance");
    for (var i = 0; i < autoAdvanceInputs.length; i++) {
      var input = autoAdvanceInputs[i];
      input.addEventListener("input", function(e) {
        if (event.target.value.length == 2) {
          var tabIndex = event.target.tabIndex;
          document.getElementsByTagName('input')[tabIndex].focus();
        }
      });
    }
  </script>
  <button type="submit" class="button">Verify</button>
</form>

Text Content

https://d3sjaxzllw9rho.cloudfront.net/clinic_images/clinic_profiles/5152/thumb_1ffa056a254d7043f7cc87f71dcfc8ca.jpeg


HACKHAM MEDICAL CENTRE

08 8392 0333

Please verify your identity to read your health message from Dr James Brew.

Please fill out all fields.

Your Last Name
Your Date of Birth

Verify


ABOUT THIS RECALL SERVICE

At Hackham Medical Centre we use a secure electronic 'recall & reminder service'
so we may notify you of upcoming due appointments and procedures. This system
also allows you to easily book your appointment by phone or online where
applicable.


UNABLE TO VERIFY?

This could mean your patient record at Hackham Medical Centre doesn't match what
you have entered. Please ensure you are typing your last name and date of birth
as supplied at the time of registration. Alternatively contact us on 08 8392
0333 to book your appointment directly.


DO YOU WISH TO OPT-OUT?

If you no longer wish to receive recall SMSs from Hackham Medical Centre ,
please click this link.