fom.li Open in urlscan Pro
188.114.97.3  Public Scan

Form analysis
1 forms found in the DOM

Name: bfahDQgd2Z —

<form name="bfahDQgd2Z" id="bfahDQgd2Z">
  <div class="block">
    <div class="block show-slow box-0">
      <div class="widget widget-w-pics"><span class="ah ai aj ak al am"><label data-baseweb="form-control-label" class="an ao ap aq ai ag ar as at au av">,<!-- --> <span class="text-gray-600 text-sm">(Optional)</span></label></span>
        <div data-baseweb="form-control-container" class="ai aw">
          <div class="grid grid-cols-3 md:grid-cols-5 gap-3" aria-describedby="bui1">
            <div class="border-4 hover:bg-opacity-100 overflow-hidden cursor-pointer relative bg-white bg-opacity-40 select-none rounded-md ">
              <div class="aspect-w-3 aspect-h-3"><img src="https://formsure-forms.s3.amazonaws.com/60c5967d85b312eede22ff64/1712858459261-2940624243.jpg" alt="Informe_médico" loading="lazy"></div>
              <p class="px-2 py-1 text-base bottom-0">Informe_médico</p>
            </div>
          </div>
          <div data-baseweb="form-control-caption" id="bui1" class="an ax ay az b0 as at au av aj ak al am"></div>
        </div>
      </div>
    </div>
    <div class="hidden">
      <div class="field field-short short"><span class="ah ai aj ak al am"><label data-baseweb="form-control-label" class="an ao ap aq ai ag ar as at au av">Correo electrónico</label></span>
        <div data-baseweb="form-control-container" class="ai aw">
          <div data-baseweb="input" class="b1 ah b2 ai b3 b4 b5 b6 b7 b8 b9 ba bb bc bd be bf bg bh an ax ay az bi bj bk bl bm bn bo">
            <div data-baseweb="base-input" class="ah ai bp bc bd an ax ay az ag bm"><input type="text" aria-describedby="bui2" aria-invalid="false" aria-required="false" autocomplete="on" inputmode="text" name="yNZCzjmweD"
                placeholder="Correo electrónico" value="" class="b1 bq br bs bt bu bv bw bx by bz ai c0 c1 c2 c3 c4 c5 c6 c7 an ax ay az ag c8 c9"></div>
          </div>
          <div data-baseweb="form-control-caption" id="bui2" class="an ax ay az b0 as at au av aj ak al am"></div>
        </div>
      </div>
    </div>
    <div class="hidden">
      <div class="field field-short short"><span class="ah ai aj ak al am"><label data-baseweb="form-control-label" class="an ao ap aq ai ag ar as at au av">Contraseña</label></span>
        <div data-baseweb="form-control-container" class="ai aw">
          <div data-baseweb="input" class="b1 ah b2 ai b3 b4 b5 b6 b7 b8 b9 ba bb bc bd be bf bg bh an ax ay az bi bj bk bl bm bn bo">
            <div data-baseweb="base-input" class="ah ai bp bc bd an ax ay az ag bm"><input type="text" aria-describedby="bui3" aria-invalid="false" aria-required="false" autocomplete="on" inputmode="text" name="ybhBKkffNP" placeholder="Contraseña"
                value="" class="b1 bq br bs bt bu bv bw bx by bz ai c0 c1 c2 c3 c4 c5 c6 c7 an ax ay az ag c8 c9"></div>
          </div>
          <div data-baseweb="form-control-caption" id="bui3" class="an ax ay az b0 as at au av aj ak al am"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="grid grid-cols-2 gap-1 max-w-max"><button data-baseweb="button" type="button" disabled="" class="ca cb cc cd br bt bs bu bv bx bw by bz ce cf cg ch bc ci cj ck cl cm am cn ak co an ao ap aq cp cq cr cs as au av at ct cu cv cw cx"><svg
        xmlns="http://www.w3.org/2000/svg" viewBox="0 0 24 24" width="24" height="24">
        <path fill="none" d="M0 0h24v24H0z"></path>
        <path d="M8 12l6-6v12z" fill="rgba(255,255,255,1)"></path>
      </svg>
      <p class="sr-only">Previous</p>
    </button><button data-baseweb="button" type="button" class="ca cb cc cd br bt bs bu bv bx bw by bz ce cf cg ch bc ci cj ck cl cm am cn ak co an ao ap aq cp cq cr cs as au av at cw cv cx cy ct cu"><svg xmlns="http://www.w3.org/2000/svg"
        viewBox="0 0 24 24" width="24" height="24">
        <path fill="none" d="M0 0h24v24H0z"></path>
        <path d="M16 12l-6 6V6z" fill="rgba(255,255,255,1)"></path>
      </svg>
      <p class="sr-only">Next</p>
    </button></div>
</form>

Text Content

SECRETARIA DE SALUD

Debido a que está accediendo a datos confidenciales, inicie sesión para ver el
documento.

, (Optional)

Informe_médico


Correo electrónico

Contraseña


Previous

Next