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index.html
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<!doctype html>
<html lang="en">
<head>
<title>Doctor Appointment Form </title>
<meta name="viewport" content="width=device-width, initial-scale=1">
<script type="application/x-javascript"> addEventListener("load", function() { setTimeout(hideURLbar, 0); }, false); function hideURLbar(){ window.scrollTo(0,1); } </script>
<!-- font files -->
<link href="//fonts.googleapis.com/css?family=Open+Sans" rel="stylesheet">
<!-- /font files -->
<!-- css files -->
<link href="css/style.css" rel='stylesheet' type='text/css' media="all" />
<!-- /css files -->
<script type="text/javascript" src="js/jquery-2.1.4.min.js"></script>
<script src="js/jquery.vide.min.js"></script>
</head>
<body>
<div data-vide-bg="video/patient">
<div class="center-container">
<h1 class="header-w3ls">Doctor Appointment Form</h1>
<div class="content-top">
<div class="content-w3ls">
<div class="form-w3ls">
<form action="#" method="post">
<div class="content-wthree1">
<div class="grid-agileits1">
<div class="form-control">
<label class="header">Name <span>*</span></label>
<input type="text" id="name" name="name" placeholder="Name" title="Please enter your Full Name" required="">
</div>
<div class="form-control">
<label class="header">Email <span>*</span></label>
<input type="email" id="email" name="email" placeholder="[email protected]" title="Please enter a Valid Email Address" required="">
</div>
<div class="form-control">
<label class="header">Phone Number <span>*</span></label>
<input type="text" id="name" name="phone number" placeholder="Phone Number" title="Please enter your Phone Number" required="">
</div>
</div>
</div>
</div>
<div class="form-w3ls-1">
<div class="form-control">
<label class="header">Address <span>*</span></label>
<input type="text" id="name" name="name" placeholder="Address" title="Please enter your Address" required="">
<input type="text" id="name" name="name" placeholder="Line" title="Please enter your Line" required="">
<input type="text" id="name" name="name" placeholder="City" title="Please enter your City" required="">
<input type="text" id="name" name="name" placeholder="Zip code" title="Please enter your Zip code" required="">
</div>
<div class="wthreesubmitaits">
<input type="submit" name="submit" value="Submit">
</div>
</form>
</div>
<div class="clear"></div>
</div>
<div class="content-w3ls">
<div class="form-w3ls">
<div class="content-wthree2">
<div class="grid-w3layouts1">
<div class="w3-agile1">
<label class="rating">Best time to call you <span>*</span></label>
<ul>
<li>
<input type="radio" id="a-option" name="selector1">
<label for="a-option">Morning </label>
<div class="check"></div>
</li>
<li>
<input type="radio" id="b-option" name="selector1">
<label for="b-option">Afternoon</label>
<div class="check"><div class="inside"></div></div>
</li>
<li>
<input type="radio" id="c-option" name="selector1">
<label for="c-option">Evening </label>
<div class="check"><div class="inside"></div></div>
</li>
</ul>
</div>
</div>
<div class="clear"></div>
</div>
</div>
<div class="form-w3ls-1">
<div class="grid-w3layouts1">
<div class="w3-agile1">
<label class="rating">I would like to (choose one)<span>*</span></label>
<ul>
<li>
<input type="radio" id="d-option" name="selector2">
<label for="d-option">A new patient appointment</label>
<div class="check"></div>
</li>
<li>
<input type="radio" id="e-option" name="selector2">
<label for="e-option">A routine checkup</label>
<div class="check"><div class="inside"></div></div>
</li>
<li>
<input type="radio" id="f-option" name="selector2">
<label for="f-option">A comprehensive health exam </label>
<div class="check"><div class="inside"></div></div>
</li>
</ul>
</div>
</div>
</div>
<div class="clear"></div>
</div>
</div>
</div>
</div>
</body>
</html>