j3health.icorepay.tech
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URL:
https://j3health.icorepay.tech/
Submission: On July 18 via api from US — Scanned from US
Submission: On July 18 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
<form id="form">
<!--<img class="mb-4 img-fluid logo" src="../../pages/assets/img/icorepay-logo-green.png" alt="" width="200px" height="100%">-->
<h1 class="h3 mb-4 fw-normal">J3 HEALTHWATCH Health and Wellness</h1>
<div class="row mt-4 pt-4">
<h4 class="h4 fw-normal text-center">Enter Amount</h4>
<div class="col-md-12 text-center enteramount">
<div class="mb-4">
<input type="text" class="form-control" name="amount" data-type="text" data-required="yes" data-error="Please enter Amount to pay" placeholder="PHP 0.00">
<!--<label for="floatingInput">Amount</label>-->
</div>
</div>
</div>
<div class="row mt-4 pt-4">
<div class="col-md-12">
<div class="form-floating mb-2">
<input type="text" class="form-control" name="reference_no" data-type="text" data-required="no" data-error="Please enter your Reference Number">
<label for="floatingInput">Reference Number</label>
</div>
</div>
<div class="col-md-12">
<div class="form-floating mb-2">
<input type="text" class="form-control" name="fullname" data-type="text" data-required="yes" data-error="Please enter your Full Name">
<label for="floatingInput">Full Name</label>
</div>
</div>
<div class="col-md-12">
<div class="form-floating mb-2">
<input type="text" class="form-control" name="email" data-type="email" data-required="yes" data-error="Please enter your Email Address" data-type-error="Please enter a valid Email Address.">
<label for="floatingInput">Email</label>
</div>
</div>
<div class="col-md-12">
<div class="form-floating mb-2">
<input type="text" class="form-control" name="address" data-type="text" data-required="yes" data-error="Please enter Address">
<label for="floatingInput">Address</label>
</div>
</div>
<div class="col-md-12">
<div class="form-floating mb-2">
<input type="text" class="form-control" name="remark" data-type="text" data-required="yes" data-error="Please enter Remarks">
<label for="floatingInput">Remarks</label>
</div>
</div>
</div>
<div class="row mt-4 pt-4">
<div class="accordion paymentacc" id="accordionExample">
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button" type="button" data-bs-toggle="collapse" data-bs-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne">
<div class="d-md-flex justify-content-between">
<div>E-wallet</div>
<div class="d-flex flex-wrap small-icon justify-content-between align-items-center">
<!--<div class=""><img src="pages//assets//img/paymaya-icon.png" /></div>
<div class=""><img src="pages//assets//img/grabpay-icon.png" /></div>
<div class=""><img src="pages//assets//img/tayocash-icon.png" /></div>-->
</div>
</div>
</button>
</h2>
<div id="collapseOne" class="accordion-collapse collapse show" data-bs-parent="#accordionExample">
<div class="accordion-body">
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="grabpaywallet" value="dp-grpy" name="payment_option[]"> <img src="pages//assets//img/grabpay-icon.png">
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="paymayaonline" value="dp-pymy" name="payment_option[]"> <img src="pages//assets//img/paymaya-icon.png">
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="tayocash" value="dp-tayo" name="payment_option[]"> <img src="pages//assets//img/tayocash-icon.png">
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="xendit-gcash" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/gcash-icon.png">
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="tayocash" value="xendit-shopeepay" name="payment_option[]"> ShopeePay
</div>
<!--<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="gcash" value="xendit-cashalo" name="payment_option[]"> Cashalo
</div>-->
</div>
<!--<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/starpay-icon.png" />
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/zybi-tech-inc-icon.png" />
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/ussc-icon.png" />
</div>
</div>-->
<!--<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"> <img src="pages//assets//img/qrph-logo.png" />
</div>
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="xendit" value="xendit" name="payment_option[]"> <img src="pages//assets//img/xendit-icon.png" />
</div>
</div>-->
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseOTC" aria-expanded="false" aria-controls="collapseTwo">
<div class="d-flex justify-content-between">
<div>OTC</div>
<div class="d-flex small-icon justify-content-between">
<!--<div class=""><img src="pages//assets//img/bpi-icon.png" /></div>
<div class=""><img src="pages//assets//img/unionbank-icon.png" /></div>
<div class=""><img src="pages//assets//img/rcbc-icon.png" /></div>-->
</div>
</div>
</button>
</h2>
<div id="collapseOTC" class="accordion-collapse collapse" data-bs-parent="#accordionExample">
<div class="accordion-body">
<div class="d-flex justify-content-between">
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="bpionline" value="xendit-svn" name="payment_option[]"> 7/11
</div>
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="unionbankonline" value="xendit-cebuana" name="payment_option[]"> Cebuana Lhuiller
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="rcbconline" value="xendit-mlhuiller" name="payment_option[]"> Mlhuiller
</div>
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="gcash" value="xendit-palawan" name="payment_option[]"> Palawan Pawnshop
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="gcash" value="xendit-ecpay" name="payment_option[]"> Dragon Pay ECPAY LOAN
</div>
</div>
<!--<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" style="height:10px; width:auto" src="/pages/assets/img/chinabank-icon.png" />
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/pnb-icon.png" />
</div>
</div>-->
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseCrypto" aria-expanded="false" aria-controls="collapseTwo">
<div class="d-flex justify-content-between">
<div>Cyrpto</div>
<div class="d-flex small-icon justify-content-between">
<!--<div class=""><img src="pages//assets//img/bpi-icon.png" /></div>
<div class=""><img src="pages//assets//img/unionbank-icon.png" /></div>
<div class=""><img src="pages//assets//img/rcbc-icon.png" /></div>-->
</div>
</div>
</button>
</h2>
<div id="collapseCrypto" class="accordion-collapse collapse" data-bs-parent="#accordionExample">
<div class="accordion-body">
<div class="d-flex justify-content-between">
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="bpionline" value="dp-aaa" name="payment_option[]" data-min="500"> Dragonpay Triple A
</div>
<div class="form-check" style="color: black;">
<input class="form-check-input" type="radio" id="unionbankonline" value="dp-bitc" name="payment_option[]" data-min="500"> Dragonpay CoinsPH
</div>
</div>
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
<div class="d-flex justify-content-between">
<div>Direct Debit</div>
<div class="d-flex small-icon justify-content-between">
<!--<div class=""><img src="pages//assets//img/bpi-icon.png" /></div>
<div class=""><img src="pages//assets//img/unionbank-icon.png" /></div>
<div class=""><img src="pages//assets//img/rcbc-icon.png" /></div>-->
</div>
</div>
</button>
</h2>
<div id="collapseTwo" class="accordion-collapse collapse" data-bs-parent="#accordionExample">
<div class="accordion-body">
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="bpionline" value="dp-bpia" name="payment_option[]"> <img src="pages//assets//img/bpi-icon.png">
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="unionbankonline" value="dp-ubpb" name="payment_option[]"> <img src="pages//assets//img/unionbank-icon.png">
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="rcbconline" value="dp-rcdd" name="payment_option[]"> <img src="pages//assets//img/rcbc-icon.png">
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/cebuana-icon.png">
</div>
<!--<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]">v<img class="img-fluid" src="/pages/assets/img/aub-icon.png" />
</div>-->
</div>
<!--<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" style="height:30px; width:auto" src="/pages/assets/img/landbank-icon.png" />
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/metrobank-icon.png" />
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" style="height:10px; width:auto" src="/pages/assets/img/chinabank-icon.png" />
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/pnb-icon.png" />
</div>
</div>-->
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseThree" aria-expanded="false" aria-controls="collapseTwo">
<div class="d-flex justify-content-between">
<div>QRPH</div>
<div class="d-flex small-icon justify-content-between">
<!--<div class=""><img src="pages//assets//img/qrph-logo.png" /></div>-->
</div>
</div>
</button>
</h2>
<div id="collapseThree" class="accordion-collapse collapse" data-bs-parent="#accordionExample">
<div class="accordion-body">
<div class="form-check mb-2" style="width:100% !important;">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"> <img src="pages//assets//img/qrph-logo.png">
</div>
<!--<hr>
<div class="mb-2">Thrift Banks</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/allbank-icon.png" />
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/psbank-icon.png" />
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" style="height:10px; width:auto" src="/pages/assets/img/queenbank-icon.png" />
</div>
</div>
<div class="mb-2">Rural Banks</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" src="/pages/assets/img/cebuana-icon.png" />
</div>
<div class="form-check">
<input class="form-check-input" type="radio" id="gcash" value="gcash-qr" name="payment_option[]"><img class="img-fluid" style="height:30px; width:auto" src="/pages/assets/img/rural-bank-guinobatan-icon.png" />
</div>
</div>-->
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseFour" aria-expanded="false" aria-controls="collapseTwo">
<div class="d-flex justify-content-between">
<div>Credit Card</div>
<div class="d-flex small-icon justify-content-between">
<!--<div class=""><img src="pages//assets//img/xendit-icon.png" /></div>-->
</div>
</div>
</button>
</h2>
<div id="collapseFour" class="accordion-collapse collapse" data-bs-parent="#accordionExample">
<div class="accordion-body">
<div class="form-check mb-2" style="width:100% !important;">
<input class="form-check-input" type="radio" id="xendit" value="xendit-cc" name="payment_option[]"> <img src="pages//assets//img/xendit-icon.png">
</div>
<!--<hr>
<div class="mb-2">Retail Outlets</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<img class="img-fluid" src="/pages/assets/img/cebuana-icon.png" />
</div>
<div class="form-check">
<img class="img-fluid" src="/pages/assets/img/7-eleven-icon.png" />
</div>
</div>
<div class="mb-2">E-wallets</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<img class="img-fluid" src="/pages/assets/img/grabpay-icon.png" />
</div>
<div class="form-check">
<img class="img-fluid" src="/pages/assets/img/maya-icon.png" />
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<img class="img-fluid" style="height:30px; width:auto" src="/pages/assets/img/shopee-pay-icon.png" />
</div>
<div class="form-check">
<img class="img-fluid" src="/pages/assets/img/gcash-icon.png" />
</div>
</div>
<div class="mb-2">Direct Debit</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<img class="img-fluid" style="height:30px; width:auto" src="/pages/assets/img/rcbc-icon.png" />1
</div>
<div class="form-check">
<img class="img-fluid" style="height:30px; width:auto" src="/pages/assets/img/bpi-icon.png" />
</div>
</div>
<div class="d-flex justify-content-between">
<div class="form-check">
<img class="img-fluid" style="height:25px; width:auto" style="height:10px; width:auto" src="/pages/assets/img/unionbank-icon.png" />
</div>
</div>-->
</div>
</div>
</div>
</div>
</div>
<div class="row mt-4 pt-4">
<div class="col-md-12">
<div class="d-flex justify-content-evenly">
<div>
<div class="form-check">
<!--<input class="form-check-input form-group" type="checkbox" value="" id="flexCheckDefault">-->
<input type="checkbox" class="form-control form-group form-check-input" value="" data-type="confirm-box" data-required="yes" data-error="Please click on the checkbox.">
<label class="form-check-label text-dark" for="flexCheckDefault">Terms and Conditions. <a href="/terms-and-conditions.html" class="text-dark">Click Here</a></label>
</div>
</div>
<div>
<div class="form-check">
<!--<input class="form-check-input" type="checkbox" value="" id="flexCheckDefault2">-->
<input type="checkbox" class="form-control form-group form-check-input" value="" data-type="confirm-box" data-required="yes" data-error="Please click on the checkbox.">
<label class="form-check-label text-dark" for="flexCheckDefault2">Privacy Policy. <a href="/privacy-policy.html" class="text-dark">Click Here</a></label>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="form-floating mt-4 pb-4">
<button class="w-100 btn btn-lg btn-primary pay">Pay</button>
</div>
</div>
<div class="row mb-4 pb-4">
<div class="col-md-12">
<p class="text-center text-dark">Powered by:</p>
</div>
<div class="col-md-12 mb-4">
<div class="d-flex justify-content-evenly align-items-center">
<img style="height:40px; width:auto" src="/pages/assets/img/icorepay-logo-green.png">
</div>
</div>
<div class="col-md-12">
<p class="text-center text-dark">In partnership with:</p>
</div>
<div class="col-md-12">
<div class="d-flex justify-content-evenly align-items-center">
<img style="height:25px; width:auto" src="/pages/assets/img/qrph-logo.png"> <img style="height:25px; width:auto" src="/pages/assets/img/xendit-icon.png"> <img style="height:35px; width:auto" src="/pages/assets/img/dragonpay-icon.png">
</div>
</div>
</div>
<!--<div class="form-floating mb-2">
<input type="email" class="form-control" id="floatingInput" placeholder="name@example.com">
<label for="floatingInput">Email address</label>
</div>
<div class="form-floating mb-2">
<input type="password" class="form-control" id="floatingPassword" placeholder="Password">
<label for="floatingPassword">Password</label>
</div>
<div class="checkbox mb-3">
<label>
<input type="checkbox" value="remember-me"> Remember me
</label>
</div>
<div class="row">
<div class="col col-md-6 col-xs-12">
<button class="w-100 btn btn-lg btn-primary mb-3" type="submit">Login</button>
<a class="w-100 btn btn-lg btn-primary" onclick="location.href='schedule.html'">Login</a>
</div>
<div class="col col-md-6 col-xs-12">
<a class="w-100 btn btn-lg btn-primary" onclick="location.href='register.html'">Register</a>
</div>
</div>
<p class="mt-5 mb-3 text-muted copyright">Mazda © 2021</p>-->
</form>Text Content
J3 HEALTHWATCH HEALTH AND WELLNESS ENTER AMOUNT Reference Number Full Name Email Address Remarks E-WALLET ShopeePay OTC 7/11 Cebuana Lhuiller Mlhuiller Palawan Pawnshop Dragon Pay ECPAY LOAN CYRPTO Dragonpay Triple A Dragonpay CoinsPH DIRECT DEBIT QRPH CREDIT CARD Terms and Conditions. Click Here Privacy Policy. Click Here Pay Powered by: In partnership with: