</ iframe > </noscript> <header class="abt-header"> <div class="abt-page__wrapper abt-flex"> <div class="abt-topnav__mobile abt-flex__col-xs-1"> <i class="abt-icon icon-Hamburger"></i> </div> <div class="abt-flex__col-xs-5 abt-flex__col-md-6 abt-align--left"> <a href="/"> <img class="abt_site_header_left_image" src="/Images/eScreenLogoWhite.png" alt="Escreen logo"></a> </div> <div class="abt-flex__col-xs-6 abt-flex__col-md-6 abt-align--right"> <img class="abt_site_header_right_image" src="/Images/AbbottLogoWhite.png" alt="Abbott"> </div> </div> </header> <nav class="abt-topnav"> <div class="abt-flex abt-page__wrapper"> <i class="abt-icon icon-X_Close"></i> <ul id="abt-topnav__menu"> <li></li> </ul> <ul id="abt-topnav__login"> <li><a href="/Authentication/Login">Login</a></li> <li><a href="/UserAccount/Add">Create account</a></li> </ul> </div> </nav> <main class="abt-main" role="main"> <div class="abt-page__body abt-page__wrapper"> <h1 class="abt-application-title abt-space__xs__m-b-xl">eSCREEN EXPRESS</h1> <section> <h2>Create User Account</h2> <form action="/UserAccount/Add" method="post"><input name="__RequestVerificationToken" type="hidden" value="gyljWm0vduVlJhoTSt1dNjaf0eYIAbjnQAW0Gv5stw-3-_5Hl--6p-c_lDOEc63B_rM3dA8V-vORRGLC6n1NLBfNYYoQwsS5Ycd8O2zvIDM1" /> <div> <div> <input id="CountryCode" name="CountryCode" type="hidden" value="US" /> <input id="RequestedInfoOptionsSelected" name="RequestedInfoOptionsSelected" type="hidden" value="" /> <div class="abt-form__wrapper abt-form__wrapper--error"> <div class="validation-summary-valid" data-valmsg-summary="true"><ul><li style="display:none"></li> </ul></div> </div> </div> </div> <div class="abt-flex"> <div class="abt-flex__col-xs-12 abt-flex__col-lg-6"> <p> Please fill out the form below to register for eScreen Express.<br /> Required fields are indicated with an asterisk (*) </p> <h3><label for="">User Profile</label></h3> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">First Name</label> </span> <input class="editorValueControl" data-val="true" data-val-required="First Name Is Required" id="FirstName" name="FirstName" onkeyup="return autoTab(this, 40, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Last Name</label> </span> <input class="editorValueControl" data-val="true" data-val-required="Last Name Is Required" id="LastName" name="LastName" onkeyup="return autoTab(this, 40, event);" type="text" value="" /> </div> </div> </div> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Address 1</label> </span> <input class="editorValueControl" data-val="true" data-val-required="Address Is Required" id="Address1" name="Address1" onkeyup="return autoTab(this, 100, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Address 2</label> </span> <input class="editorValueControl" id="Address2" name="Address2" onkeyup="return autoTab(this, 100, event);" type="text" value="" /> </div> </div> </div> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">City</label> </span> <input class="editorValueControl" data-val="true" data-val-required="City Is Required" id="City" name="City" onkeyup="return autoTab(this, 32, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">State</label> </span> <select data-val="true" data-val-required="State Is Required" id="SelectedState" name="SelectedState"><option value="">- - Select - -</option> <option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AS">American Samoa</option> <option value="AZ">Arizona</option> <option value="AR">Arkansas</option> <option value="AA">Armed Forces Americas</option> <option value="AE">Armed Forces Europe</option> <option value="AP">Armed Forces Pacific</option> <option value="BM">Bermuda</option> <option value="CA">California</option> <option value="CO">Colorado</option> <option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="DC">District of Columbia</option> <option value="FM">Federated States of Micronesia</option> <option value="FL">Florida</option> <option value="GA">Georgia</option> <option value="GU">Guam</option> <option value="HI">Hawaii</option> <option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option> <option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option> <option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MH">Marshall Islands</option> <option value="MD">Maryland</option> <option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option> <option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option> <option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option> <option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option> <option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="MP">Northern Mariana Islands</option> <option value="OH">Ohio</option> <option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option> <option value="PR">Puerto Rico</option> <option value="PW">Republic of Palau</option> <option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option> <option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option> <option value="VT">Vermont</option> <option value="VI">Virgin Islands</option> <option value="VA">Virginia</option> <option value="WA">Washington</option> <option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option> </select> </div> </div> </div> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Zip Code</label> </span> <input class="eScreenZipCode UnitedStatesZipCode" data-val="true" data-val-regex="Please enter a valid Postal Code." data-val-regex-pattern="\d{5}" data-val-required="Postal Code is required" id="PostalCode_PostalPartOne" name="PostalCode.PostalPartOne" onkeyup="return autoTab(this, 5, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper "> <span class="abt-input__label abt-input__label--required"> <label for="">Phone Number</label> </span> <input class="eScreenPhone UnitedStatedPhone" data-val="true" data-val-regex="Please enter a valid Phone Number." data-val-regex-pattern="^\d{3}$" data-val-required="Please enter a valid Phone Number." id="PhoneNumber_AreaCode" name="PhoneNumber.AreaCode" onkeyup="return autoTab(this, 3, event);" type="text" value="" /> - <input class="eScreenPhone UnitedStatedPhone" data-val="true" data-val-regex="Please enter a valid Phone Number." data-val-regex-pattern="^\d{3}$" data-val-required="Please enter a valid Phone Number." id="PhoneNumber_Prefix" name="PhoneNumber.Prefix" onkeyup="return autoTab(this, 3, event);" type="text" value="" /> - <input class="eScreenPhone UnitedStatedPhone" data-val="true" data-val-regex="Please enter a valid Phone Number." data-val-regex-pattern="^\d{4}$" data-val-required="Suffix is required" id="PhoneNumber_Suffix" name="PhoneNumber.Suffix" onkeyup="return autoTab(this, 4, event);" type="text" value="" /> <!--single input phone number--> </div> </div> </div> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Email</label> </span> <input class="editorValueControl" data-val="true" data-val-required="Email Address Is Required" id="EmailAddress" name="EmailAddress" onkeyup="return autoTab(this, 320, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper"> <div class="abt-input__label abt-input__label--required"> <label for="">Confirm Email</label> </div> <div class="abt-input__label"> <input class="editorValueControl" data-val="true" data-val-required="Email Address Is Required" id="ConfirmEmailAddress" name="ConfirmEmailAddress" onkeyup="return autoTab(this, 320, event);" type="text" value="" /> </div> </div> </div> </div> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label"> <label for="">Company Name</label> </span> <input class="editorValueControl" id="CompanyName" name="CompanyName" onkeyup="return autoTab(this, 200, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper"> <span class="abt-input__label"> <label for="">Access Code</label> </span> <input class="editorValueControl" id="AccessCode" name="AccessCode" onkeyup="return autoTab(this, 200, event);" type="text" value="" /> </div> </div> <div class="abt-flex__col-sm-6--gutters"></div> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters"> <div class="abt-alert--minimal abt-color--primary"> <i class="abt-icon--x2 icon-Messaging abt-space__xs-t-xs"></i> <div class="abt-alert--minimal__text" style="margin-top: -0.3rem"> <p> By entering an Access Code, you authorize eScreen to share your results with the employer associated with such Access Code. </p> </div> </div> </div> </div> <h3 class="abt-space__sm__m-t-xl"><label for="">Create Password</label></h3> <p class="abt-space__sm__m-b-sm"> <label for="">Passwords must be between 8 and 15 characters with 1 uppercase letter, 1 lowercase letter, and 1 number or special character.</label> </p> <div class="abt-flex"> <div class="abt-flex__col-xs-12--gutters abt-flex__col-sm-6--gutters abt-space__sm__m-r-xl"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Password</label> </span> <input autocomplete="off" class="editorValueControl" data-val="true" data-val-required="Password Is Required" id="PasswordOne" name="PasswordOne" onkeyup="return autoTab(this, 15, event);" type="password" /> </div> </div> <div class="abt-flex__col-xs-12--gutters abt-form__wrapper abt-flex__col-sm-6--gutters"> <div class="abt-form__wrapper"> <span class="abt-input__label abt-input__label--required"> <label for="">Confirm Password</label> </span> <input autocomplete="off" class="editorValueControl" data-val="true" data-val-required="Confirm Password Is Required" id="PasswordTwo" name="PasswordTwo" onkeyup="return autoTab(this, 15, event);" type="password" /> </div> </div> </div> <h3 class="abt-space__sm__m-t-xl"><label for="">Terms & Conditions</label></h3> <div id="divInfoOption"> <div class="abt-input__checkboxgroup"> <div class=" abt-space__sm__m-b-md abt-form__wrapper"> <div><div><div class=""><input id="RequestedInfoOptions_1" name="RequestedInfoOptions_1" type="checkbox" value="true" /><input name="RequestedInfoOptions_1" type="hidden" value="false" /><label for="Yes__send_me_eScreen_Sales_and_Marketing_Information">Yes, send me eScreen Sales and Marketing Information.</label></div></div></div> </div> <div class=" abt-space__sm__m-b-md abt-form__wrapper"> <div class="abt-input__force-inline"><input id="AcceptTermsAndConditions" name="AcceptTermsAndConditions" type="checkbox" value="true" /><input name="AcceptTermsAndConditions" type="hidden" value="false" /><label for="I_have_read_and_accept_the">I have read and accept the</label></div> <div id="abt-termsLink"> <a href="/Information/TermsAndConditions" target="_blank">Terms and Conditions</a> </div> <label class="abt-space__xs__m-l-none abt-input__label-helper" for="">of use.*</label> </div> </div> </div> </div> </div> <div class="abt-space__xs__m-b-xl"> <input type="submit" value="Next" class="abt-btn abt-btn--primary abt-btn-margin--right" /> <a class="abt-btn abt-btn--secondary" href="/">Cancel</a> </form> </div> </section> </div> </main> <footer class="abt-footer"> <span id="consent-banner" class="fixed-banner"></span> <div class="abt-page__wrapper abt-flex"> <div class="abt-flex__col-xs-12 abt-flex__col-md-3"> <img class="abt_site_footer_left_image " src="/Images/AbbottLogoWhite.png" alt="Abbott logo" /> </div> <div class="abt-flex__col-xs-12 abt-flex__col-md-9"> <div class="abt_site_footer_links"> <a><span id="teconsent"></span></a> <a href="https://www.abbott.com/privacy-policy/consumer-health-data.html" target="_blank">Consumer Health Data Privacy Policy</a> <a href="https://www.abbott.com/privacy-policy.html" target="_blank">Privacy Policy</a> <a href=/Information/TermsAndConditions target="_blank" class="item active">Terms of Use</a> <a href="https://www.escreen.com/us/home/contact.html" target="_blank">Contact Us</a> </div> </div> <div class="abt-flex__col-xs-12"> <div class="abt_site_footer_limited_content"> © 2024 eScreen, Inc. All rights reserved. All trademarks referenced are trademarks of either the Abbott group <br /> of companies or their respective owners. </div> </div> </div> </footer> <script type="text/javascript"> $(document).ready(function () { $(function () { $('#divInfoOption').find('input[type=checkbox]').each(function () { $(this).click(function () { UpdateRequestedInfoOptionsSelected(); }); }); }); }); function UpdateRequestedInfoOptionsSelected() { var value = ""; $('#divInfoOption').find('input[type=checkbox]').each(function () { $('#RequestedInfoOptionsSelected').attr('value', ""); if ($(this).attr('checked')) { var id = $(this).attr('id'); value += id.substring(id.lastIndexOf("_") + 1) + "|"; $('#RequestedInfoOptionsSelected').attr('value', value); } }); //jQuery(function ($) { // $("#PhoneNumber").mask("(999) 999-9999"); //}); //$(":input").inputmask(); } </script> </body> </html>