struct |
addresscatlist |
none
|
bodycontent |
<a name="par1"></a> <h1>Registrieren (Internet / Brief)</h1>
<form action="/index.cfm?content=pwilleregonoff&spr=de&debug=1&lv=1" name="contactform" method="post" style="margin-top: 20px;" onsubmit="return checkOkOnSubmit('contactform');">
<input type="hidden" name="formname" value="contactform" />
<input type="hidden" name="contact_action" value="act_contact" />
<input type="hidden" name="acatlist" value="1000" />
<input type="hidden" name="paragraph" value="1" />
<input type="hidden" name="checktype" value="1" />
<div id="contactform">
<input type="hidden" name="adr_format" value="onlineoffline" />
<div class="frow">
<div class="add_title">Name </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_name" title="Name" value="Name" maxlength="80" /></div>
</div>
<div class="frow">
<div class="add_title">Vorname </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_firstname" title="Vorname" value="Vorname" maxlength="40" /></div>
</div>
<div class="frow">
<div class="add_title">Geb. Datum </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_dateofbirth" title="Geb. Datum" value="" maxlength="10" /></div>
</div>
<div class="frow">
<div class="add_title">Versicherungs-Nr./AHV-Nr. <a id="help_dsp_nummer" class="help_box_file" target="_blank" href="/index.cfm?action=act_getfile&doc_id=100001&spr=de&debug=1&lv=1"> </a></div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_description1" title="Versicherungs-Nr./AHV-Nr." value="" maxlength="100" /></div>
</div>
<div class="frow">
<div class="add_title">Heimatort </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_description2" title="Heimatort" value="" maxlength="100" /></div>
</div>
<div class="frow">
<div class="add_title">Strasse, Nr. </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_street1" title="Strasse, Nr." value="" maxlength="80" /></div>
</div>
<div class="frow">
<div class="add_title">PLZ / Ort </div>
<div class="input">
<input class="inputFeldzip" style="" type="text" name="adr_zip" value="5210" title="PLZ" maxlength="10" />
<input class="inputFeldcity" style="" type="text" name="adr_city" value="Windisch" title="Ort" maxlength="40" />
</div>
</div>
<div class="frow">
<div class="add_title">E-Mail Privat </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_emailhome" title="E-Mail Privat" value="" maxlength="80" /></div>
</div>
<div class="frow">
<div class="add_title">Passwort </div>
<div class="input"><input class="inputFeld" style="" type="password" name="apwd_password" title="Passwort" value="" maxlength="80" /></div>
</div>
<div class="frow" style="height: 50px;">
<div class="add_title">Sicherheitsprüfung <a class="help_box" id="help_dsp_spamcheck" href="javascript:"> </a></div>
<div class="input">
<input type="hidden" name="checknumber" value="8" />
<span>
<select name="spamcheck" size="1" title="Spam-Check" class="inputFeldspam">
<option value="">-</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select>
Wählen Sie die folgende Zahl aus: <span class="spamnumber">acht</span>
</span>
</div>
</div>
<div class="frow">
<div class="add_title"><input type="submit" name="submitter" value="Senden" class="butttonformat" /></div>
<div class="input"></div>
</div>
</div>
</form>
<div id="warnings">Fehlermeldung</div>
<br style="clear:both;" /><br><br>Nach dem Absenden erhalten Sie umgehend zwei E-Mails. Im ersten E-Mail<br>sehen Sie Ihre Zugangsdaten. Mit dem zweiten E-Mail schalten Sie Ihr<br>Benutzerkonto frei.<br> <br /><br /><a href="/index.cfm?content=20&&spr=de&debug=1&lv=1" class="linkformat">zurück zur Übersicht</a>
|
lastaddressform |
struct |
adr_city |
Windisch
|
adr_emailoffice |
error.urban.obrist@3way.ch
|
adr_firstname |
Vorname
|
adr_name |
Name
|
adr_sex |
1
|
adr_zip |
5210
|
|
lasturl |
https://www.patientenwille.ch?&content=pwilleregonoff&debug=1&lv=1
|
login |
struct |
ADR_CITY |
[empty string]
|
ADR_CUSTOMERADRNR |
[empty string]
|
ADR_CUSTOMERNR |
[empty string]
|
ADR_DATEOFBIRTH |
[empty string]
|
ADR_DESCRIPTION1 |
[empty string]
|
ADR_DESCRIPTION2 |
[empty string]
|
ADR_EMAILOFFICE |
[empty string]
|
ADR_FIRSTNAME |
[empty string]
|
ADR_ID |
[empty string]
|
ADR_KEY |
[empty string]
|
ADR_LANG |
[empty string]
|
ADR_NAME |
[empty string]
|
ADR_STREET1 |
[empty string]
|
ADR_TYPE |
[empty string]
|
ADR_ZIP |
[empty string]
|
APWD_ERPLOGIN |
[empty string]
|
APWD_ERPPASSWORD |
[empty string]
|
APWD_LOGIN |
[empty string]
|
APWD_PASSWORD |
[empty string]
|
addresscatlist |
none
|
creditlimit |
[empty string]
|
customersortiment |
[empty string]
|
discount |
0
|
discountfactor |
1
|
|
loginok |
0
|
mobile |
0
|
naviaccesslist |
suggest,sitemap,shop,search,rss,pwilleshow,pwilleregonoff,pwillereg,print,pdf,newsletter,mobile,login,impressum,home,format,favourite,contact,b60,b50,b40,b30,b20,b10,60,50,40,35,30,20
|
pazalastcontent |
[empty string]
|
pazalastmoduleurlparam |
[empty string]
|
pazalasturl |
[empty string]
|
today |
getdate()
|
Registrieren (Internet / Brief)
Fehlermeldung
Nach dem Absenden erhalten Sie umgehend zwei E-Mails. Im ersten E-Mail
sehen Sie Ihre Zugangsdaten. Mit dem zweiten E-Mail schalten Sie Ihr
Benutzerkonto frei.
zurück zur Übersicht
struct |
addresscatlist |
none
|
bodycontent |
<a name="par1"></a> <h1>Registrieren (Internet / Brief)</h1>
<form action="/index.cfm?content=pwilleregonoff&spr=de&debug=1&lv=1" name="contactform" method="post" style="margin-top: 20px;" onsubmit="return checkOkOnSubmit('contactform');">
<input type="hidden" name="formname" value="contactform" />
<input type="hidden" name="contact_action" value="act_contact" />
<input type="hidden" name="acatlist" value="1000" />
<input type="hidden" name="paragraph" value="1" />
<input type="hidden" name="checktype" value="1" />
<div id="contactform">
<input type="hidden" name="adr_format" value="onlineoffline" />
<div class="frow">
<div class="add_title">Name </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_name" title="Name" value="Name" maxlength="80" /></div>
</div>
<div class="frow">
<div class="add_title">Vorname </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_firstname" title="Vorname" value="Vorname" maxlength="40" /></div>
</div>
<div class="frow">
<div class="add_title">Geb. Datum </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_dateofbirth" title="Geb. Datum" value="" maxlength="10" /></div>
</div>
<div class="frow">
<div class="add_title">Versicherungs-Nr./AHV-Nr. <a id="help_dsp_nummer" class="help_box_file" target="_blank" href="/index.cfm?action=act_getfile&doc_id=100001&spr=de&debug=1&lv=1"> </a></div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_description1" title="Versicherungs-Nr./AHV-Nr." value="" maxlength="100" /></div>
</div>
<div class="frow">
<div class="add_title">Heimatort </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_description2" title="Heimatort" value="" maxlength="100" /></div>
</div>
<div class="frow">
<div class="add_title">Strasse, Nr. </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_street1" title="Strasse, Nr." value="" maxlength="80" /></div>
</div>
<div class="frow">
<div class="add_title">PLZ / Ort </div>
<div class="input">
<input class="inputFeldzip" style="" type="text" name="adr_zip" value="5210" title="PLZ" maxlength="10" />
<input class="inputFeldcity" style="" type="text" name="adr_city" value="Windisch" title="Ort" maxlength="40" />
</div>
</div>
<div class="frow">
<div class="add_title">E-Mail Privat </div>
<div class="input"><input class="inputFeld" style="" type="text" name="adr_emailhome" title="E-Mail Privat" value="" maxlength="80" /></div>
</div>
<div class="frow">
<div class="add_title">Passwort </div>
<div class="input"><input class="inputFeld" style="" type="password" name="apwd_password" title="Passwort" value="" maxlength="80" /></div>
</div>
<div class="frow" style="height: 50px;">
<div class="add_title">Sicherheitsprüfung <a class="help_box" id="help_dsp_spamcheck" href="javascript:"> </a></div>
<div class="input">
<input type="hidden" name="checknumber" value="8" />
<span>
<select name="spamcheck" size="1" title="Spam-Check" class="inputFeldspam">
<option value="">-</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
</select>
Wählen Sie die folgende Zahl aus: <span class="spamnumber">acht</span>
</span>
</div>
</div>
<div class="frow">
<div class="add_title"><input type="submit" name="submitter" value="Senden" class="butttonformat" /></div>
<div class="input"></div>
</div>
</div>
</form>
<div id="warnings">Fehlermeldung</div>
<br style="clear:both;" /><br><br>Nach dem Absenden erhalten Sie umgehend zwei E-Mails. Im ersten E-Mail<br>sehen Sie Ihre Zugangsdaten. Mit dem zweiten E-Mail schalten Sie Ihr<br>Benutzerkonto frei.<br> <br /><br /><a href="/index.cfm?content=20&&spr=de&debug=1&lv=1" class="linkformat">zurück zur Übersicht</a>
|
lastaddressform |
struct |
adr_city |
Windisch
|
adr_emailoffice |
error.urban.obrist@3way.ch
|
adr_firstname |
Vorname
|
adr_name |
Name
|
adr_sex |
1
|
adr_zip |
5210
|
|
lasturl |
https://www.patientenwille.ch?&content=pwilleregonoff&debug=1&lv=1
|
login |
struct |
ADR_CITY |
[empty string]
|
ADR_CUSTOMERADRNR |
[empty string]
|
ADR_CUSTOMERNR |
[empty string]
|
ADR_DATEOFBIRTH |
[empty string]
|
ADR_DESCRIPTION1 |
[empty string]
|
ADR_DESCRIPTION2 |
[empty string]
|
ADR_EMAILOFFICE |
[empty string]
|
ADR_FIRSTNAME |
[empty string]
|
ADR_ID |
[empty string]
|
ADR_KEY |
[empty string]
|
ADR_LANG |
[empty string]
|
ADR_NAME |
[empty string]
|
ADR_STREET1 |
[empty string]
|
ADR_TYPE |
[empty string]
|
ADR_ZIP |
[empty string]
|
APWD_ERPLOGIN |
[empty string]
|
APWD_ERPPASSWORD |
[empty string]
|
APWD_LOGIN |
[empty string]
|
APWD_PASSWORD |
[empty string]
|
addresscatlist |
none
|
creditlimit |
[empty string]
|
customersortiment |
[empty string]
|
discount |
0
|
discountfactor |
1
|
|
loginok |
0
|
mobile |
0
|
naviaccesslist |
suggest,sitemap,shop,search,rss,pwilleshow,pwilleregonoff,pwillereg,print,pdf,newsletter,mobile,login,impressum,home,format,favourite,contact,b60,b50,b40,b30,b20,b10,60,50,40,35,30,20
|
pazalastcontent |
[empty string]
|
pazalastmoduleurlparam |
[empty string]
|
pazalasturl |
[empty string]
|
today |
getdate()
|