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Form analysis
1 forms found in the DOM

Name: wf-form-signup-form — POST #

<form _ngcontent-pwn-c1="" action="#" class="needs-validation ng-untouched ng-pristine ng-invalid" data-name="Validation Form" id="verification" method="post" name="wf-form-signup-form" novalidate=""><input _ngcontent-pwn-c1="" name="xsrf_token"
    type="hidden" value="e0513465b47975732c06fb20bcdacbcef9bc84bf"><!---->
  <p _ngcontent-pwn-c1="" class="help-text pt-3 max-w-600px mx-auto">Welcome to the Secure MDPay Payment Interface for Birmingham Gastroenterology Associates:</p><!---->
  <div _ngcontent-pwn-c1="" class="form-group form-group-name max-w-600px mx-auto"><label _ngcontent-pwn-c1="" class="label-form-control d-block required" for="firstName"> First Name </label><input _ngcontent-pwn-c1="" autocomplete="off"
      class="form-control form-control-firstname w-100 required ng-untouched ng-pristine ng-invalid" formcontrolname="isFirstNameReq" id="firstName" name="isFirstNameReq" required="" spellcheck="false" title="Enter First Name"
      type="text"><!----><!----></div><!---->
  <div _ngcontent-pwn-c1="" class="form-group form-group-name max-w-600px mx-auto"><label _ngcontent-pwn-c1="" class="label-form-control d-block required" for="lastname"> Last Name </label><input _ngcontent-pwn-c1="" autocomplete="off"
      class="form-control form-control-lastname w-100 required ng-untouched ng-pristine ng-invalid" formcontrolname="isLastNameReq" id="lastname" name="isLastNameReq" required="" spellcheck="false" title="Enter Last Name" type="text"><!----><!---->
  </div><!----><!----><!----><!---->
  <div _ngcontent-pwn-c1="" class="form-group form-group-name max-w-600px mx-auto"><label _ngcontent-pwn-c1="" class="label-form-control d-block required" for="lastname"> Date of Birth </label><input _ngcontent-pwn-c1="" autocomplete="off"
      class="form-control form-control-dobm masked w-100 required ng-untouched ng-pristine ng-invalid" formcontrolname="dateOfBirth" id="dateOfBirth" name="dateOfBirth" placeholder="mm/dd/yyyy" required="" spellcheck="false"
      title="Enter Date of Birth" type="tel"><!----><!----></div>
  <div _ngcontent-pwn-c1="" class="position-relative form-group form-group-submit max-w-600px mx-auto pt-5 mb-5 text-center"><button _ngcontent-pwn-c1="" class="btn btn-primary w-100 d-flex justify-content-center" id="formSubmit" type="submit"><span
        _ngcontent-pwn-c1="">Login</span></button></div>
</form>

Text Content

PATIENT CENTER

Welcome to the Secure MDPay Payment Interface for Birmingham Gastroenterology
Associates:

First Name
Last Name
Date of Birth
Login
205-271-8000
1 Independence Plaza
Available Chat Hours: 08:00 AM - 05:00 PM