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

<style>

.cicrimg {
    margin-bottom: -28%;
    width: 54%;
    margin-top: 6%;
}
.buildh3 {
    font-size: 24px;
    width: 24%;
}
.buildimg {
    height: 450px;
}

.form-group {
    position: relative;
    margin-bottom: 12px;
}
label {
    font-weight: bold !important;
    font-size: 14px !important;
    margin-bottom: 0px !important;
    color: #193778 !important;
}
.form-control {
    border: 1px solid #fff;
}
.form-control {
    border: 1px solid #000;
}
.form-control {
    margin: 1em 0;
}
.form-control {
    height: 45px;
    border: 1px solid #193778;
    background-color: transparent;
    border-radius: 1px;
    padding: 0 0 0 20px;
    border-radius: 50px;
    margin: 4px 0px 17px 0px;
}
.form-control:focus {
    border-color: #193778;
}
.form-control, .form-control:focus, button, button:focus {
    outline: 0;
    background-color: transparent;
    -webkit-box-shadow: none;
    -ms-box-shadow: none;
    -o-box-shadow: none;
    box-shadow: none;
}
.mb-10 {
        margin-bottom: 10px;
}
.pcvwbtn {
    width: 36%;
}

.allbtn {
    font-size: 16px;
    padding: 10px 24px;
}
</style>



<section class="inner-banner bg-light">
    <div class="container">
        <div class="row align-items-center intro-title">
            <div class="col-12">
                <ol class="breadcrumb mb-0">
                    <li class="breadcrumb-item"><a href="#"> <i class="fas fa-home"></i> </a></li>
                    <li class="breadcrumb-item active"> <i class="fas fa-chevron-right"></i> <span>Book An Appointment</span></li>
                </ol>
            </div>
        </div>
    </div>
</section>



<!--<section class="pt-100">-->
<!--    <div class="container">-->
<!--        <div class="sec-title-style1 text-center max-width">-->
<!--            <div class="text-center">-->
<!--                <h3 class="center animated slideInDown"><span>Our  </span>Story</h3>-->
<!--            </div>-->
<!--            <div class="text"><div class="decor-left"><span></span></div><p>Lorem Ipsum</p><div class="decor-right"><span></span></div></div>-->
<!--            <div class="bottom-text">-->
<!--                <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 1500s</p>-->
<!--            </div>-->
<!--        </div>-->
<!--    </div>-->
<!--</section>-->

<section class="ptb-100 pt-15" style="background: #f6f6f6;">
    <div class="container">
            <div class="row">
                <div class="col-md-6">
                    <!--<p><b>Common Questions </b></p>-->
                    <h3 class="center animated slideInDown" style="text-align: left;"><span>Book an   </span><br>Appointment</h3>
                    <p style="    width: 88%;
    text-align: justify;">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 1500s, when an unknown printer took a galley of type and scrambled it to make a type specimen book. </p><br>
                    <div class="frm">
                        <p>In case, if you want to reach us directly:</p>
                        <!--<h4 style="color: #193778;font-weight: 600;font-size: 28px;">24x7 Helpline: </h4>-->
                        <div class="mb-10">
                        <i class="fa-solid fa-phone fafaicon" aria-hidden="true"></i>&nbsp; <span style="color: #d81159;    font-weight: 600;">  24x7 Helpline:</span>
                        </div>
                        <h4 style="color: #193778;font-weight: 600;font-size: 28px;">+91 00000 00000 </h4><br>
                        
                        <div class="mb-10">
                        <i class="fa-solid fa-phone fafaicon" aria-hidden="true"></i>&nbsp; <span style="color: #d81159;    font-weight: 600;">  24x7 Emergency:</span>
                        </div>
                        <h4 style="color: #193778;font-weight: 600;font-size: 28px;">+91 00000 00000 </h4>
                        
                        
                        <!--<i class="fa-solid fa-phone fafaicon" aria-hidden="true"></i> <span style="color: #d81159;"> 24x7 Helpline: +91 00000 00000</span><br><br>-->
                        <!--<i class="fa-solid fa-phone fafaicon" aria-hidden="true"></i> <span style="color: #d81159;"> 24x7 Emergency: +91 00000 00000</span>-->
                    </div>
                </div>
                <div class="col-md-6">
                    <form method="post" action="#" enctype="multipart/form-data">
                        <div class="row">
                            <div class="col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label>Patient Name *</label>
                                    <input type="text" class="form-control" placeholder="Enter Your Name" id="contactname" name="contactname" aria-required="true" required="">
                                </div>
                            </div>
                
                            <div class="col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label>Email *</label>
                                    <input type="email" class="form-control" placeholder="Enter Your Email ID" id="contactemail" name="contactemail" aria-required="true" required="">
                                </div>
                            </div>
                
                            <div class="col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label>Phone * </label>
                                    <input type="tel" name="contactphone" id="mobile" placeholder="Enter Your Phone No" class="form-control" data-error="Contact field is required" onkeypress="return isNumberKey(event) " minlength="10" maxlength="10" required="">
                                </div>
                            </div>
                            
                            <div class="col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label>Date * </label>
                                    <input name="appointment_date" id="app_date" type="date" placeholder="Date of Appointment" title="Enter alphabets only" class="form-control input-md" style="padding-right: 20px;">
                                </div>
                            </div>
                            
                            
                            <div class="col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label>Select Speciality </label>
                                    <select class="form-control form-field" name="selectpurpose" id="selectpurpose" required="">
                                        <option value="Lorem">Lorem</option>
                                        <option value="Lorem">Lorem</option>
                                        <option value="Lorem">Lorem</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-sm-12 col-md-6 col-lg-6">
                                <div class="form-group">
                                    <label>Select Doctor </label>
                                    <select class="form-control form-field" name="selectpurpose" id="selectpurpose" required="">
                                        <option value="Lorem">Dr. Lorem Ipsum</option>
                                        <option value="Lorem">Dr. Lorem Ipsum</option>
                                        <option value="Lorem">Dr. Lorem Ipsum</option>
                                    </select>
                                </div>
                            </div>
                
                            <div class="col-sm-12 col-md-12 col-lg-12">
                                <div class="form-group">
                                    <label>Message</label>
                                    <textarea class="form-control" placeholder="Enter your Message" id="contactmessgae" name="contactmessgae" aria-required="true" required="" style="height: 100px;padding-top: 17px;border-radius: 17px;"></textarea>
                                </div>
                            </div>
                            <div class="row" style="display:none;">
                                   <div class="col-md-4">
                                <label for="files" class="upload-file" style="    font-size: 13px;">Upload PAN Card</label><input type="file" name="file[]">
                                </div>
                                    <div class="col-md-4">
                                <label for="files" class="upload-file" style="    font-size: 13px;">Upload Adhar </label>
                                <input type="file" name="file[]">
                                </div>
                                     <div class="col-md-4">
                                <label for="files" class="upload-file" style="    font-size: 13px;"> Bank Statement</label>
                                <input type="file" name="file[]">
                                </div>
                            </div>
                
              
                              
                            <div class="col-sm-12 col-md-12 col-lg-12">
                                <a href="" class="wht allbtn pcvwbtn">Submit</a>
                                <!--<input name="submit" type="submit" value="Submit" class="form-in-sub">-->
                                <div class="contact-result"></div>
                            </div>
              </div>
       </form>
                </div>
                
            </div>
            
        </div>
</section>

    
    
    
  

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