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Mini Shell

Direktori : /home/importfo/www/divinemultispeciality.com/
Upload File :
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>

Zerion Mini Shell 1.0