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Directory : /var/www/html/shardahospital_old.org/hbackup/application/views/
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| Current File : /var/www/html/shardahospital_old.org/hbackup/application/views/booking.php |
<?php include('includes/header.php'); ?>
<!--BreadcrumbsStart-->
<section id="breadcrumbs">
<div class="container van-booking-head">
<div class="row">
<div class="col-md-12">
<h1>Aarogya Mammography Van Booking</h1>
</div>
<div class="col-md-12">
<ul>
<li><a href="/">Sharda Hospital</a></li>
<li>Aarogya Mammography Van Booking</li>
</ul>
</div>
</div>
</div>
</section>
<!--BreadcrumbsEnd-->
<!--MainDIV-Start-->
<section id="main">
<div class="container">
<div class="row">
<div id="contact_us" class="van-booking-form">
<form action="" method="POST" name="vanbooking">
<div class="col-md-6 col-sm-6">
<ul class="list-unstyled width">
<input type="hidden" name="id" id="id" value="<?=$_POST['id']?>" >
<li><h4>Name of the Rotary Club<span style="color:red">*</span></h4>
<input type="text" name="club_name" id="club_name" value="<?=$_POST['club_name']?>" maxlength="200" required placeholder="Name of the Rotary Club">
</li>
<li><h4>Name of Contact Person<span style="color:red">*</span></h4>
<input type="text" name="contact_person" id="contact_person" value="<?=$_POST['contact_person']?>" required placeholder="E.g. Arun George" maxlength="200" >
</li>
<li><h4>Email Id of Contact Person<span style="color:red">*</span></h4>
<input type="email" name="email_id" id="email_id" maxlength="149" value="<?=$_POST['email_id']?>" required placeholder="E.g. xyz@abc.com">
</li>
<li><h4>Road Condition to Reach Camp<span style="color:red">*</span></h4>
<input type="text" name="road_condition" id="road_condition" value="<?=$_POST['road_condition']?>" required placeholder="Road Condition to Reach Camp" maxlength="250" >
</li>
<li><h4>Expected No. of Patients to Attend the camp<span style="color:red">*</span></h4>
<input type="text" name="expected_no" onkeyup="this.value=this.value.replace(/[^\d]/,'')" autocomplete="off" id="expected_no" value="<?=$_POST['expected_no']?>" required placeholder="E.g. 100" maxlength="4" >
</li>
<li><h4>Address<span style="color:red">*</span></h4>
<input type="text" name="full_address" id="full_address" value="<?=$_POST['full_address']?>" required placeholder="Address" maxlength="250">
</li>
<li><h4>State<span style="color:red">*</span></h4>
<input type="text" name="state" id="state" value="<?=$_POST['state']?>" required placeholder="State" maxlength="250">
</li>
<li><h4>Booking Ammount<span style="color:red">*</span></h4>
<p>Rs. 10,000</p>
</li>
</ul>
</div>
<div class="col-md-6 col-sm-6">
<ul class="list-unstyled">
<li><h4>Date of Booking<span style="color:red">*</span></h4>
<?php
$bookingDate = $_POST['booking_date']=='' ? '' : date('d-m-Y',strtotime($_POST['booking_date']));
?>
<input type="text" name="booking_date" id="booking_date" value="<?=$bookingDate?>" required placeholder="Date of Booking" maxlength="50">
<script type="text/javascript">
$(function () {
$('#booking_date').datetimepicker({
format: 'DD-MM-YYYY',
<?php if($bookingDate=='') { ?>
minDate: moment().add('d', 1).toDate(),
<?php } ?>
defaultDate: ''
});
});
</script>
</li>
<li><h4>Name of Camp Site<span style="color:red">*</span></h4>
<input type="text" name="camp_site_name" id="camp_site_name" value="<?=$_POST['camp_site_name']?>" maxlength="200" required placeholder="Name of Camp Site" maxlength="250">
</li>
<li><h4>Distance from Sharda Hospital , Greater Noida<span style="color:red">*</span></h4>
<input type="text" name="distance_from_shospital" id="distance_from_shospital" maxlength="250" value="<?=$_POST['distance_from_shospital']?>" required placeholder="E.g. 5 KM" autocomplete="off" maxlength="50">
</li>
<li><h4>Contact No<span style="color:red">*</span></h4>
<input type="text" name="contact_no" id="contact_no" value="<?=$_POST['contact_no']?>" axlength="2" required placeholder="E.g. xxxxxxxxxx" onkeyup="this.value=this.value.replace(/[^\d]/,'')" autocomplete="off" maxlength="10">
</li>
<li><h4>Alternative No. if any Available</h4>
<input type="text" name="alternate_contact_no" id="alternate_contact_no" value="<?=$_POST['alternate_contact_no']?>" placeholder="E.g. 0120-xxxxxxx" maxlength="30">
</li>
<li><h4>City<span style="color:red">*</span></h4>
<input type="text" name="city" id="city" required value="<?=$_POST['city']?>" placeholder="City" maxlength="150">
</li>
<li><h4>Pincode<span style="color:red">*</span></h4>
<input type="text" name="pincode" id="pincode" required value="<?=$_POST['pincode']?>" onkeyup="this.value=this.value.replace(/[^\d]/,'')" placeholder="pincode" maxlength="6">
</li>
<li><h4>Mode of Payment<span style="color:red">*</span></h4>
<p>Online</p>
</li>
</ul>
</div>
<div class="col-md-12 col-sm-6" >
<p><input style="width:auto; margin-right:10px; margin-top:20px;" type="checkbox" checked="checked" name="agree" id="agree" value="1" disabled /> I accept <a href="https://www.shardahospital.org/pages/terms-conditions" target="_blank" style="color:blue;">terms & condition</a></p>
</div>
<div class="clearfix"></div>
<div class="col-md-8 col-xs-12">
<input type="submit" class="button1" value="Book Now" name="submit" />
</div>
<!--<button type="submit" class="btn_orange btn-default">Send message</button></div>-->
</form>
</div>
</div>
</div>
</section>
<!--MainDIV-End-->
<!--form-validation-start-->
<link href="//cdn.rawgit.com/Eonasdan/bootstrap-datetimepicker/e8bddc60e73c1ec2475f827be36e1957af72e2ea/build/css/bootstrap-datetimepicker.css" rel="stylesheet">
<script src="//cdnjs.cloudflare.com/ajax/libs/moment.js/2.9.0/moment-with-locales.js"></script>
<script src="//cdn.rawgit.com/Eonasdan/bootstrap-datetimepicker/e8bddc60e73c1ec2475f827be36e1957af72e2ea/src/js/bootstrap-datetimepicker.js"></script>
<?php include('includes/footer.php'); ?>
<!--form-validation-end-->
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