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Current File : /home/importfo/www/divinemultispeciality.com/form.php |
<div class="quickLinks-wrap js-quickLinks-wrap-d d-none d-lg-flex"> <div class="quickLinks js-quickLinks"> <div class="container"> <div class="row no-gutters"> <div class="col"> <a href="#" class="link"> <i class="icon-placeholder"></i><span>Location</span></a> <div class="link-drop p-0"> <!-- <div id="googleMapDrop" class="google-map"></div> --> <div class="map-responsive"> <iframe src="https://www.google.com/maps/embed?pb=!1m14!1m8!1m3!1d14669.69248288165!2d72.6067401!3d23.1912458!3m2!1i1024!2i768!4f13.1!3m3!1m2!1s0x395c29d4a4e603fb%3A0xf2d3148017024304!2sDivine%20Multispeciality%20Hospital!5e0!3m2!1sen!2sin!4v1691641806920!5m2!1sen!2sin" width="100%" height="400" style="border:0;" allowfullscreen="" loading="lazy" referrerpolicy="no-referrer-when-downgrade"></iframe> </div> </div> </div> <div class="col"> <a href="#" class="link"> <i class="icon-clock"></i><span>Working Time</span> </a> <div class="link-drop"> <h5 class="link-drop-title"><i class="icon-clock"></i>Working Time</h5> <table class="row-table"> <tr> <td><i>Monday-Satday</i></td> <td>Open 24 hours</td> </tr> </table> </div> </div> <div class="col"> <a href="#" class="link"> <i class="icon-pencil-writing"></i><span>Request Form</span> </a> <div class="link-drop"> <h5 class="link-drop-title"><i class="icon-pencil-writing"></i>Request Form</h5> <form id="requestForm" method="post" novalidate> <div class="successform"> <p>Your message was sent successfully!</p> </div> <div class="errorform"> <p>Something went wrong, try refreshing and submitting the form again.</p> </div> <div class="input-group"> <span> <i class="icon-user"></i> </span> <input name="requestname" type="text" class="form-control" placeholder="Your Name" /> </div> <div class="row row-sm-space mt-1"> <div class="col"> <div class="input-group"> <span> <i class="icon-email2"></i> </span> <input name="requestemail" type="text" class="form-control" placeholder="Your Email" /> </div> </div> <div class="col"> <div class="input-group"> <span> <i class="icon-smartphone"></i> </span> <input name="requestphone" type="text" class="form-control" placeholder="Your Phone" /> </div> </div> </div> <div class="selectWrapper input-group mt-1"> <span> <i class="icon-right-arrow"></i> </span> <select name="requestservice" class="form-control"> <option selected="selected" disabled="disabled">Select Service</option> <option value="Medical Services">Medical Services</option> <option value="Pediatric Services">Pediatric Services</option> <option value="Support Services">Support Services </option> <option value="Diagnostic Service">Diagnostic Service</option> <option value="Pathology">Pathology</option> </select> </div> <div class="row row-sm-space mt-1"> <div class="col-sm-6"> <div class="input-group flex-nowrap"> <span> <i class="icon-calendar2"></i> </span> <div class="datepicker-wrap"> <input name="requestdate" type="text" class="form-control datetimepicker" placeholder="Date" readonly> </div> </div> </div> <div class="col-sm-6 mt-1 mt-sm-0"> <div class="input-group flex-nowrap"> <span> <i class="icon-clock"></i> </span> <div class="datepicker-wrap"> <input name="requesttime" type="text" class="form-control timepicker" placeholder="Time" readonly> </div> </div> </div> </div> <div class="text-right mt-2"> <button type="submit" class="btn btn-sm btn-hover-fill">Request</button> </div> </form> </div> </div> <!-- <div class="col"> <a href="#" class="link"> <i class="icon-calendar"></i><span>Doctors Timetable</span> </a> <div class="link-drop"> <h5 class="link-drop-title"><i class="icon-calendar"></i>Doctors Timetable</h5> <p>This simply works as a guide and helps you to connect with dentists of your choice. Please confirm the doctor’s availability before leaving your premises.</p> <p class="text-right"><a href="schedule.php" class="btn btn-sm btn-hover-fill">Details</a></p> </div> </di --> <!-- <div class="col"> <a href="#" class="link"> <i class="icon-price-tag"></i><span>Calculator</span> </a> <div class="link-drop"> <h5 class="link-drop-title"><i class="icon-price-tag"></i>Quick Pricing</h5> <table class="row-table"> <tr> <td>Initial Consultation</td> <td>$10</td> </tr> <tr> <td>Dental check-up</td> <td>$15</td> </tr> <tr> <td>Routine Exam (no xrays)</td> <td>$50</td> </tr> <tr> <td>Simple Removal of a tooth</td> <td>$122</td> </tr> <tr> <td>Teeth cleaning</td> <td>$50 - $75</td> </tr> <tr> <td>X-ray image</td> <td>$10</td> </tr> </table> <p class="text-right mt-15"><a href="prices.php" class="btn btn-sm btn-hover-fill">Calculator</a><a href="prices.php" class="btn btn-sm btn-hover-fill">Details</a></p> </div> </div> --> <!-- <div class="col"> <a href="#" class="link"> <i class="icon-emergency-call"></i><span>Emergency Case</span></a> <div class="link-drop"> <h5 class="link-drop-title"><i class="icon-emergency-call"></i>Emergency Case</h5> <p>Emergency dental care may be needed if you have had a blow to the face, lost a filling, or cracked a tooth. </p> <ul class="icn-list"> <li><i class="icon-telephone"></i><span class="phone">1-800-267-0000<br>1-800-267-0001</span> </li> <li><i class="icon-black-envelope"></i><a href="mailto:info@besthotel-email.com">info@besthotel-email.com</a></li> </ul> <p class="text-right mt-2"><a href="contact.php" class="btn btn-sm btn-hover-fill">Our Contacts</a></p> </div> </div> --> <div class="col"> <a href="#" class="link"> <i class="icon-emergency-call"></i><span>Contact</span></a> <div class="link-drop"> <h5 class="link-drop-title"><i class="icon-emergency-call"></i>Conatact Us</h5> <p>Mediclaim/ cashless facility also available</p> <ul class="icn-list"> <li><i class="icon-telephone"></i><span class="phone">+91 78618 12967 </span> </li> <li><i class="icon-black-envelope"></i><a href="docrohanjobanputra@gmail.com">demo@gmail.com</a></li> </ul> <p class="text-right mt-2"><a href="contact.php" class="btn btn-sm btn-hover-fill">Our Contacts</a></p> </div> </div> <div class="col col-close"><a href="#" class="js-quickLinks-close"><i class="icon-top" data-toggle="tooltip" data-placement="top" title="Close panel"></i></a></div> </div> </div> <div class="quickLinks-open js-quickLinks-open"><span data-toggle="tooltip" data-placement="left" title="Open panel">+</span></div> </div> </div>