<?php include 'header.php';?>

<style>


.commonbanner {
    /*background: url(./images/banner/general.webp);*/
    background: url(./images/banner/share-feedback.webp);
    margin-left: auto;
    margin-right: auto;
    background-position: center !important;
    background-size: cover !important;
    background-repeat: no-repeat !important;
    background-attachment: scroll !important;
}
.breadcrumb {
    margin-left: auto;
    margin-right: auto;
    display: flex;
    font-weight: 400;
}
.brdcrumbwht.active {
    color: #000;
    z-index: 9;
}
.page-title-heading p {
    text-align: left;
    width: 56%;
    /*color: #193778;*/
}
.center {
    text-align: justify;
    font-size: 38px;
}
.ttm-page-title-row-inner {
    padding: 73px 0px 61px;
}

</style>

        <div class="ttm-page-title-row commonbanner">
            <div class="ttm-page-title-row-inner ttm-bgcolor-darkgrey">
                <div class="container">
                    <div class="row align-items-center">
                        <div class="col-lg-12">
                            <div class="page-title-heading">
                                 <h3 class="center" style="z-index: 999;position: relative;color:#193778;"><span style="color:#193778;"> Share Your Feedback</span></h3>
                                 <p>Lorem Ipsum is simply dummy text of the printing and typesetting industry. Lorem Ipsum has been the industry's standard dummy text ever since the 1500.</p>
                            </div>
                            <ol class="breadcrumb mb-0">
                                <li class="breadcrumb-item bditm"><a href="#"> <i class="fas fa-home" style="color: #000;"></i> </a></li>
                                <li class="breadcrumb-item brdcrumbwht"> <i class="fas fa-chevron-right"></i> Patient Portal</li>
                                <li class="breadcrumb-item brdcrumbwht active"> <i class="fas fa-chevron-right"></i> Share Your Feedback</li>
                            </ol>
                        </div>
                    </div>
                </div>
            </div>                    
        </div>
        
        
<section class="contact-info-area">
    <div class="container">
        <div class="row">
            <div class="col-xl-12 col-lg-12 col-md-12 col-sm-12">
                <div class="contact-form">
                    <!--<div class="row">-->
                    <!--    <div class="col-xl-12">-->
                    <!--        <div class="sec-title-style1 float-left">-->
                    <!--            <div class="text-center">-->
                    <!--                <h3 class="center animated slideInDown text_left"><span>Send Your </span>Message</h3>-->
                    <!--            </div>-->
                    <!--            <div class="text"><div class="decor-left"><span></span></div><p>Contact Form</p></div>-->
                    <!--        </div>-->
                    <!--        <div class="text-box float-right">-->
                    <!--            <p>Lorem Ipsum is simply dummy text of the printing and typesetting industry. </p>-->
                    <!--        </div>-->
                    <!--    </div> -->
                    <!--</div>   -->
                    <div class="inner-box">
                        <form id="contact-form" name="contact_form" class="default-form" action="inc/sendmail.php" method="post">
                            <div class="row">
                                <div class="col-xl-6 col-lg-12">
                                    <div class="row">
                                        <div class="col-xl-6">
                                            <div class="input-box">   
                                                <input type="text" name="form_name" value="" placeholder="Name" required="">
                                            </div> 
                                             <div class="input-box"> 
                                                <input type="text" name="form_phone" value="" placeholder="Phone">
                                            </div>
                                        </div>
                                        <div class="col-xl-6">
                                            <div class="input-box"> 
                                                <input type="email" name="form_email" value="" placeholder="Email" required="">
                                            </div>
                                            <div class="input-box"> 
                                                <input type="text" name="form_website" value="" placeholder="Date">
                                            </div> 
                                        </div>  
                                    </div> 
                                    <div class="row">
                                         <div class="col-xl-12">
                                            <div class="input-box"> 
                                                <input type="text" name="form_subject" value="" placeholder="Subject">
                                            </div>     
                                        </div> 
                                    </div>   
                                </div>
                                <div class="col-xl-6 col-lg-12">
                                    <div class="input-box">    
                                        <textarea name="form_message" placeholder="Your Message..." required=""></textarea>
                                    </div>
                                    <div class="button-box">
                                        <input id="form_botcheck" name="form_botcheck" class="form-control" type="hidden" value="">
                                        <button type="submit" data-loading-text="Please wait...">Send Message<span class="flaticon-next"></span></button>    
                                    </div>         
                                </div> 
                            </div>
                        </form>
                    </div>
                </div>
            </div>
            
        </div>
    </div>
</section>


        
        
        
    

<?php include 'footer.php';?>
