childrensmercy.my.salesforce-sites.com
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13.110.66.207
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Submitted URL: https://childrensmercy.secure.force.com/ReferralStatus
Effective URL: https://childrensmercy.my.salesforce-sites.com/ReferralStatus
Submission: On May 15 via manual from US — Scanned from DE
Effective URL: https://childrensmercy.my.salesforce-sites.com/ReferralStatus
Submission: On May 15 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: j_id0:frm — POST /ReferralStatus
<form id="j_id0:frm" name="j_id0:frm" method="post" action="/ReferralStatus" enctype="application/x-www-form-urlencoded">
<input type="hidden" name="j_id0:frm" value="j_id0:frm">
<div id="j_id0:frm:j_id5">
<div class="slds-grid slds-wrap slds-text-align_left custom-container">
<div class="slds-size_1-of-2 slds-m-rigrt_large slds-max-small-size_1-of-1 slds-form-element slds-lookup" data-scope="single" data-select="single">
<label class="slds-form-element__label" for="clinicId">Clinic</label>
<div class="slds-form-element__control slds-input-has-icon slds-input-has-icon--right">
<div class="slds-pill_container slds-hide"></div><input aria-autocomplete="list" aria-expanded="false" class="slds-lookup__search-input slds-input slds-input" id="clinicId" placeholder="Search Clinics" role="combobox" type="text"><input
id="j_id0:frm:clinic" type="text" name="j_id0:frm:clinic" style="display:none">
</div>
</div>
<div class="slds-size_1-of-2 slds-m-rigrt_large slds-max-small-size_1-of-1" style="padding-left: 20px">
<label class="slds-form-element__label"><abbr class="slds-required" title="required">*</abbr>Preferred Email</label>
<p id="preferredEmailVal"></p><input id="j_id0:frm:preferredEmail" type="text" name="j_id0:frm:preferredEmail" class="slds-input required slds-hide">
</div>
</div>
<div class="slds-grid slds-wrap slds-align_absolute-center slds-m-top_small slds-p-bottom_small slds-border_bottom"><input id="j_id0:frm:genetareOTP" type="submit" name="j_id0:frm:genetareOTP" value="Send Verification Code"
onclick="if(!isValid()){return false}" class="slds-button slds-button_brand">
</div>
<div class="slds-grid slds-wrap slds-text-align_left slds-m-top_small custom-container">
<div class="slds-size_1-of-2 slds-m-rigrt_xxx-small slds-max-small-size_1-of-1">
<label class="slds-form-element__label"><abbr class="slds-required" title="required">*</abbr>Enter Password</label><input id="j_id0:frm:otpProvided" type="text" name="j_id0:frm:otpProvided" class="slds-input" max="6">
</div>
<div class="slds-size_1-of-2 slds-m-rigrt_xxx-small slds-max-small-size_1-of-1">
<label class="slds-form-element__label"></label><input type="submit" name="j_id0:frm:j_id14" value="Login" class="slds-button slds-button_brand slds-m-top_large">
</div>
</div>
</div>
<div aria-describedby="modal-content-id-1" aria-labelledby="modal-heading-01" aria-modal="true" class="slds-modal" id="Modalbox" role="dialog" tabindex="-1">
<div class="slds-modal__container">
<header class="slds-modal__header">
<button class="slds-button slds-button_icon slds-modal__close slds-button_icon-inverse" title="Close">
<svg aria-hidden="true" class="slds-button__icon slds-button__icon_large">
<use xlink:href="/assets/icons/utility-sprite/svg/symbols.svg#close" xmlns:xlink="http://www.w3.org/1999/xlink"></use>
</svg>
<span class="slds-assistive-text">Close</span>
</button>
<h2 class="slds-text-heading_medium slds-hyphenate" id="modal-heading-01">Comments on Referral</h2>
</header>
<div class="slds-modal__content slds-p-around_medium" id="modal-content-id-1">
<div class="slds-tabs_scoped">
<ul class="slds-tabs_scoped__nav" role="tablist">
<li class="slds-tabs_scoped__item slds-is-active" id="viewComments" role="presentation" title="View Comments">
<a aria-controls="tab-scoped-2" aria-selected="false" class="slds-tabs_scoped__link" href="javascript:void(0);" id="tab-scoped-2__item" onclick="changeTab('viewComments');" role="tab" tabindex="-1">View Comments</a></li>
<li class="slds-tabs_scoped__item " id="addComments" role="presentation" title="Add Comments">
<a aria-controls="tab-scoped-1" aria-selected="true" class="slds-tabs_scoped__link" href="javascript:void(0);" id="tab-scoped-1__item" onclick="changeTab('addComments');" role="tab" tabindex="0">Add Comments</a></li>
</ul>
<div aria-labelledby="tab-scoped-1__item" class="slds-tabs_scoped__content slds-hide" id="addCommentSection" role="tabpanel">
<div class="modal-body">
<div class="form-group">
<label class="slds-form-element__label"><abbr class="slds" title="required">*</abbr>User Name</label><input id="j_id0:frm:userName" type="text" name="j_id0:frm:userName" class="required slds-input" style="background: #fff;"
maxlength="100" placeholder="Enter user name here">
</div>
<div class="form-group">
<label class="slds-form-element__label"><abbr class="slds" title="required">*</abbr>Comments</label><textarea id="j_id0:frm:comments" name="j_id0:frm:comments" class="required slds-input" style="background: #fff;" maxlength="255"
placeholder="Enter comments here"></textarea>
</div>
<div class="drop-zone" id="drop-zone">
<input accept=".pdf" id="file" multiple="false" name="file" type="file">
<label class="slds-file-selector__body" for="file" id="clickHere">
<span class="slds-file-selector__button slds-button slds-button_neutral">
<svg aria-hidden="true" class="slds-button__icon slds-button__icon_left slds-icon_xx-small">
<use xlink:href="/_slds/icons/utility-sprite/svg/symbols.svg#upload" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink"></use>
</svg>Upload Files</span>
</label>
<div id="filename"></div>
</div>
<div class="slds-form-element__group">
<div class="slds-form-element slds-size_1-of-1 slds-align_absolute-center">
<div id="status" style="margin:0 5px 0 0; display:none;">
<div class="slds-progress-ring" style="background: rgb(246, 249, 252);">
<div aria-valuemax="100" aria-valuemin="0" aria-valuenow="88" class="slds-progress-ring__progress" role="progressbar">
<svg viewBox="-1 -1 2 2">
<path class="slds-progress-ring__path" d="M 1 0 A 1 1 0 1 1 0.7289686274214112 -0.684547105928689 L 0 0" id="slds-progress-ring-path"></path>
<animateTransform attributeName="transform" dur="1.5s" from="360 0 0" repeatCount="indefinite" to="0 0 0" type="rotate"></animateTransform>
</svg>
</div>
<div class="slds-progress-ring__content"></div>
</div>
</div>
</div>
</div>
<div class="slds-form-element__group">
<div class="slds-form-element slds-size_1-of-1 slds-align_absolute-center">
<input class="slds-button slds-button_brand" onclick="saveModal();" type="button" value="Send Comments">
</div>
</div>
</div>
</div>
<script type="text/javascript">
var dropZoneId = "drop-zone";
var buttonId = "clickHere";
var mouseOverClass = "mouse-over";
var dropZone = $("#" + dropZoneId);
var inputFile = dropZone.find("input");
$(function() {
$("#progress").css("width", "50%");
inputFile.on('change', function(e) {
console.log('inputFile: ' + inputFile);
console.log('finalFiles: ' + finalFiles);
finalFiles = {};
var keys = Object.keys(finalFiles);
$('#filename').html("");
var fileNum = this.files.length,
initial = keys.length;
console.log('fileNum: ' + fileNum);
if (fileNum > 3) {
alert('Maximum 3 Files are allowed.');
fileNum = 0;
finalFiles = {};
$('[id$="file"]').val('');
$('[id$="filename"]').empty();
} else {
counter = 0;
$.each(this.files, function(idx, elm) {
if (elm.type == 'application/pdf') {
if (elm.size <= 1000000) {
finalFiles[getRandomInt()] = elm;
initial++;
} else {
alert('File "' + elm.name + '" is large than 1MB. This file will be skipped.');
}
} else {
alert('File "' + elm.name + '" is not PDF type. This file will be skipped.');
}
});
$('#file').val('');
$.each(finalFiles, function(initial, value) {
$('#filename').append('<div id="file_' + initial +
'"><svg class="slds-button__icon_small" aria-hidden="true"><use xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/_slds/icons/utility-sprite/svg/symbols.svg#file" /></svg> ' +
value.name +
'  <svg class="slds-button__icon_small" onclick="removeLine(this)" aria-hidden="true"><use xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/_slds/icons/utility-sprite/svg/symbols.svg#close" /></svg></div>'
);
});
}
});
});
</script>
<div aria-labelledby="tab-scoped-2__item" class="slds-tabs_scoped__content slds-show slds-scrollable" id="viewCommentSection" role="tabpanel">
<div class="slds-form slds-form_compound">
<p id="showData"></p>
</div>
</div>
</div>
</div>
<footer class="slds-modal__footer">
<input class="slds-button slds-button_brand" onclick="closeViewComments();" type="button" value="Close">
</footer>
</div>
<div id="opaque"></div>
<div id="spinner">
<p align="center" style="{font-family:"Arial", Helvetica, sans-serif; font-size:20px;}"><img src="/img/loading.gif"> Please wait</p>
</div>
</div>
<div class="slds-backdrop" id="Modalbackdrop"></div>
<script>
$(".date").datepicker({
maxDate: 0,
changeMonth: true,
changeYear: true,
yearRange: ((new Date).getFullYear() - 60) + ':' + (new Date).getFullYear()
});
</script>
<div id="j_id0:frm:j_id91"></div>
</form>Text Content
PLEASE USE GOOGLE CHROME AS YOUR INTERNET BROWSER Clinic *Preferred Email *Enter Password Close COMMENTS ON REFERRAL * View Comments * Add Comments *User Name *Comments Upload Files Please wait