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Directory : /var/www/html/shardahospital_old.org/lp/lms/
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| Current File : //var/www/html/shardahospital_old.org/lp/lms/lms_form.php |
<?php
error_reporting(0);
include('include/header.php');
include('common.php');
?>
<div class="appointment-form top-space-lg">
<div class="form-header">
<h4>MAKE AN APPOINTMENT</h4>
<a href="tel:8003456789">Call: 0120-2333999</a>
<div class="or_icon">OR</div>
</div>
<script src="js/jquery-1.11.1.js"></script>
<script src="js/syncubat_valid.js"></script>
<script src="js/jquery.validate.min.js"></script>
<style>
#res3 {
display: none;
}
#res3 {
color:#F00;
background-color: #DFF2BF;
text-align: center;
margin-right: 5px;
padding:1px;
}
#contact_form label.error {
margin-left: 10px;
width: auto;
display: inline;
color:#900;
font-size: 15px;
padding: 10px;
}
#error_msg {
color:#900;
font-size: 9px;
padding: 10px;
}
.btn_next {
display: inline-block;
padding: 6px 12px;
margin-bottom: 0;
font-size: 14px;
font-weight: 400;
line-height: 1.42857143;
text-align: center;
white-space: nowrap;
vertical-align: middle;
background-image: none;
border: 1px solid transparent;
border-radius: 4px;
}
span.validation {
font-style:italic;
color:#B41F2B;
background-color:#FFF;
}
span.loading {
font-style: italic;
left: 5px;
position: relative;
}
</style>
<?php
if($error_message) {
echo $error_message;
}
if($error_email_exist){
echo $error_email_exist;
}
if($success_message){ echo $success_message; }?> <br/>
<div id='contact_form'>
<form id="contact_form" method="POST" name="contact_form">
<div class="form-group">
<label>Full Name</label>
<input type="text" class="form-control" name="full_name" id="full_name" value="<?php echo $_POST['full_name'];?>" title="Your full name please">
</div>
<div class="form-group">
<label>Email ID</label>
<input type="email" class="form-control" name="email" id="email" value="<?php echo $_POST['email'];?>" title="We need your email address">
</div>
<div class="form-group">
<label>Phone Number</label>
<input type="text" class="form-control" name="phone" id="phone" value="<?php echo $_POST['phone'];?>" maxlength='10' title="Please enter your phone number">
</div>
<div class="form-group">
<label>Department</label>
<select class="form-control" name="department" id="department" title="Please Choose a department">
<option value="">Choose a Department</option>
<option value="General / OP" <?php echo ($department == 'General / OP')?"selected":"" ?>>General / OP</option>
<option value="Nurology" <?php echo ($department == 'Nurology')?"selected":"" ?>>Nurology</option>
<option value="Cardiac Surgery" <?php echo ($department == 'Cardiac Surgery')?"selected":"" ?>>Cardiac Surgery</option>
<option value="Dental Care" <?php echo ($department == 'Dental Care')?"selected":"" ?>>Dental Care</option>
<option value="Eye Care" <?php echo ($department == 'Eye Care')?"selected":"" ?>>Eye Care</option>
<option value="ENT Center" <?php echo ($department == 'ENT Center')?"selected":"" ?>>ENT Center</option>
</select>
</div>
<div class="form-group" id="human_date">
<label>Date and Time</label>
<input type="text" class="form-control" name="date_time" id="date_time" value="<?php echo $_POST['date_time'];?>" placeholder="eg: next monday 3pm" title="Enter Appointment date and time">
<!-- <small class="date-output"></small>
<input type="hidden" name="date_time" id="date_time">-->
</div>
<div class="form-group">
<label>Additional information</label> <small class="text-muted">(optional)</small>
<textarea class="form-control" name="message1" id="message1" rows="3" placeholder="Enter your message here"><?php echo $_POST['message1'];?> </textarea>
</div>
<div class="text-center top-space">
<input type="submit" class="btn btn-success btn-block btn-xl" id="submits" name="submits" value="Book an Appointment" />
<small class="text-muted">Hurry up, we have only limited slots this month</small>
<div id="js-contact-result" data-success-msg="Form submitted successfully." data-error-msg="Oops. Something went wrong."></div>
</div>
</form>
</div>
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