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| Current File : //var/www/html/shardahospital_old.org/application/views/ccavenue_form_oldd.php |
<?php include('includes/header.php');
?>
<script>
window.onload = function() {
var d = new Date().getTime();
document.getElementById("tid").value = d;
};
</script>
<!--BreadcrumbsStart-->
<section id="breadcrumbs">
<div class="container">
<div class="row">
<div class="col-md-12">
<h1>Medical Package</h1>
</div>
<div class="col-md-12">
<ul>
<li>Sharda Hospital</li>
<li>Medical Package</li>
</ul>
</div>
</div>
</div>
</section>
<!--BreadcrumbsEnd-->
<!--MainDIV-Start-->
<section id="main">
<div class="container">
<div class="row">
<div id="contact_us" class="col-sm-9">
<h2 class="h2inner mrg-bot30">Payment Information</h2>
<div class="row">
<div class="col-sm-10 col-sm-offset-1 col-xs-12">
<form method="post" name="customerData" id="customerData" action="<?php echo site_url('Payment/handle_request'); ?>">
<div style="display:none">
<input type="hidden" name="alternate_phone" id="name" value="">
</div>
<h4 class="h2inner mrg-bot30">Patient Details</h4>
<div>
<label>Patient Name* </label>
<input type="text" name="billing_name" value="" required placeholder="Enter Patient's Full Name" />
</div>
<p>
<label>Patient Address* </label>
<input type="text" name="billing_address" value="" required placeholder="Enter Patient's Address" />
</p>
<p>
<label>Patient Country* </label>
<input type="text" name="billing_country" value="India" required readonly />
</p>
<p>
<label>Patient State* </label>
<input type="text" name="billing_state" value="" required placeholder="Enter State"/>
</p>
<p>
<label>Patient City* </label>
<input type="text" name="billing_city" value="" required placeholder="Enter City"/>
</p>
<p>
<label>Patient Zip* </label>
<input type="text" name="billing_zip" value="" required placeholder="Enter Zip"/>
</p>
<p>
<label>Patient Mobile* </label>
<input type="text" name="billing_tel" value="" required placeholder="Enter Mobile Number"/>
</p>
<p>
<label>Patient Email* </label>
<input type="email" name="billing_email" value="" required placeholder="Enter Email-ID"/>
</p>
<h4 class="h2inner mrg-bot30">Payment Details</h4>
<div>
<input type="hidden" name="merchant_param1" value="" />
<input type="hidden" name="merchant_param2" value="<?php echo $OrderItemName ?>" />
<input type="hidden" name="merchant_param3" value="<?php echo $OrderItemID ?>" />
<input type="hidden" name="merchant_param4" value="<?php echo $OrderItemType ?>" />
<input type="hidden" name="tid" id="tid" readonly />
<input type="hidden" name="merchant_id" value="160146" />
<input type="hidden" name="order_id" value="<?php echo $OrderID ?>" required readonly />
<input type="hidden" name="redirect_url" value="<?php echo site_url('Payment/handle_response'); ?>" readonly />
<input type="hidden" name="cancel_url" value="<?php echo site_url('Payment/handle_response'); ?>" readonly />
<input type="hidden" name="language" value="EN"/>
<!-- <input type="hidden" name="delivery_name" value=""/>
<input type="hidden" name="delivery_address" value=""/>
<input type="hidden" name="delivery_city" value=""/>
<input type="hidden" name="delivery_state" value=""/>
<input type="hidden" name="delivery_zip" value=""/>
<input type="hidden" name="delivery_country" value=""/>
<input type="hidden" name="delivery_tel" value=""/>
<input type="hidden" name="promo_code" value=""/></td> -->
<input type="hidden" name="customer_identifier" value=""/>
</div>
<p>
<label>Product </label>
<input type="text" name="merchant_param5" value="<?php echo $OrderItemType ?>-<?php echo $OrderItemName ?>" required readonly/>
</p>
<p>
<label>Amount </label>
<?php echo number_format((float)$OrderAmount,2,'.','');?>
<input type="hidden" name="amount" value="<?php echo number_format((float)$OrderAmount,2,'.','');?>" required readonly />
<!-- <input type="text" name="amount" value="<?php echo $OrderAmount ?>" required readonly /> -->
</p>
<p>
<label>Currency </label>
<input type="text" name="currency" value="<?php echo $OrderCurrencyCode ?>" required readonly />
</p>
<!-- <p>
<label>TID </label>
<input type="hidden" name="tid" id="tid" readonly />
</p>
<p>
<label>Merchant Id </label>
<input type="hidden" name="merchant_id" value=""/>
</p>
<p>
<label>Order Id </label>
<input type="text" name="order_id" value="<?php echo $OrderID ?>" required readonly />
</p>
<p>
<label>Redirect URL </label>
<input type="hidden" name="redirect_url" value="<?php echo site_url('Payment/handle_response'); ?>" readonly />
</p>
<p>
<label>Cancel URL </label>
<input type="hidden" name="cancel_url" value="<?php echo site_url('Payment/handle_response'); ?>" readonly />
</p>
<p> -->
<label>Language </label>
<input type="text" name="language" value="EN"/>
</p>
<p>
<button TYPE="submit" value="CheckOut" class="btn_orange btn-default submit">Check Out</button>
</p>
</form>
</div>
</div>
</div>
</div>
</div>
</section>
<!--MainDIV-End-->
<!--form-validation-start-->
<script src="<?php echo base_url();?>assets/js/jquery.validate.js"></script>
<script>
$.validator.setDefaults({
submitHandler: function() {
$("#customerData").submit();
// alert("submitted!");
}
});
$().ready(function() {
// validate the customerData form when it is submitted
$("#customerData").validate();
// validate signup form on keyup and submit
$("#signupForm").validate({
rules: {
firstname: "required",
lastname: "required",
username: {
required: true,
minlength: 2
},
password: {
required: true,
minlength: 5
},
confirm_password: {
required: true,
minlength: 5,
equalTo: "#password"
},
email: {
required: true,
email: true
},
topic: {
required: "#newsletter:checked",
minlength: 2
},
agree: "required"
},
messages: {
firstname: "Please enter your firstname",
lastname: "Please enter your lastname",
username: {
required: "Please enter a username",
minlength: "Your username must consist of at least 2 characters"
},
password: {
required: "Please provide a password",
minlength: "Your password must be at least 5 characters long"
},
confirm_password: {
required: "Please provide a password",
minlength: "Your password must be at least 5 characters long",
equalTo: "Please enter the same password as above"
},
email: "Please enter a valid email address",
agree: "Please accept our policy",
topic: "Please select at least 2 topics"
}
});
// propose username by combining first- and lastname
$("#username").focus(function() {
var firstname = $("#firstname").val();
var lastname = $("#lastname").val();
if (firstname && lastname && !this.value) {
this.value = firstname + "." + lastname;
}
});
//code to hide topic selection, disable for demo
var newsletter = $("#newsletter");
// newsletter topics are optional, hide at first
var inital = newsletter.is(":checked");
var topics = $("#newsletter_topics")[inital ? "removeClass" : "addClass"]("gray");
var topicInputs = topics.find("input").attr("disabled", !inital);
// show when newsletter is checked
newsletter.click(function() {
topics[this.checked ? "removeClass" : "addClass"]("gray");
topicInputs.attr("disabled", !this.checked);
});
});
//mobile
$(document).ready(function() {
$('#ContactPhone').blur(function(e) {
if (validatePhone('ContactPhone')) {
$('#spnPhoneStatus').html('Valid');
$('#spnPhoneStatus').css('color', 'green');
}
else {
$('#spnPhoneStatus').html('Invalid');
$('#spnPhoneStatus').css('color', 'red');
}
});
});
function validatePhone(ContactPhone) {
var a = document.getElementById(ContactPhone).value;
var filter = /^((\+[1-9]{1,4}[ \-]*)|(\([0-9]{2,3}\)[ \-]*)|([0-9]{2,4})[ \-]*)*?[0-9]{3,4}?[ \-]*[0-9]{3,4}?$/;
if (filter.test(a)) {
return true;
}
else {
return false;
}
}
//mobile
</script>
<!--form-validation-end-->
<!--MAP-End-->
<section id="map">
<div class="container-fluid">
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12 contact-us-img">
<ul class="list-unstyled">
<li>
<h3>Sharda Hospital</h3>
<span class="glyphicon glyphicon-map-marker pull-left"></span>
<p>Sharda University Campus
Greater Noida Plot No. 32-34, Knowledge Park III,
Greater Noida, UP.- 201306</p>
</li>
<li><span class="glyphicon glyphicon-earphone pull-left"></span> <p>0120-2333999</p></li>
<li><span class="glyphicon glyphicon-envelope pull-left"></span> <p>info@shardahospital.org</p></li>
</ul>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 padding-none">
<iframe src="https://www.google.com/maps/embed?pb=!1m18!1m12!1m3!1d3507.169408441502!2d77.48051051461232!3d28.474444382480506!2m3!1f0!2f0!3f0!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x390cea9cae68659b%3A0xc95b3bd7cf26316e!2sSharda+Hospital!5e0!3m2!1sen!2sin!4v1498126204776" width="100%" height="434" frameborder="0" style="border:0" allowfullscreen></iframe>
</div>
</div>
</div>
</section>
<!--MAP-End-->
<?php include('includes/quick_links.php') ?>
<?php include('includes/subscribe.php') ?>
<?php include('includes/footer.php'); ?>
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