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

    <div id="content-wrapper">

        <div class="tt-heading">

            <div class="tt-heading-cell" style="background-image:url(wp-content/themes/dentalcare/assets/images/tmp/inner_headerg.jpg );  ">

                <div class="container">

                    <h1 style="" class="tt-heading-title h1">Appointment Doctor</h1> </div>

                <div class="tt-mslide-border"></div>

            </div>

        </div>

        <div class="doctors container main-wrapper">

            <div class="content-area">

                <div class="entry-content">

                    <div class="text_block wpb_text_column clearfix">

                        <div class="vc_row wpb_row vc_row-fluid tt-block">

                            <div class="wpb_column vc_column_container vc_col-sm-12">

                                <div class="vc_column-inner ">

                                    <div class="wpb_wrapper">

                                        <div class="vc_row wpb_row vc_inner vc_row-fluid row">

                                            <div class="col-sm-12 wpb_column vc_column_container vc_col-sm-12">

                                                <div class="col-md-7 col-md-offset-3">

                                                    <div class="wpb_wrapper">

                                                        <div class="custom-heading  no-margin">

                                                            <h4 class="tt-title h4 no-desc" style="color:#13304f"> 



			Appointment

			<span style="color:#1f6bbe"> Doctor </span>



		</h4> </div>

                                                        <div class="wpb_text_column wpb_content_element  vc_custom_1492412621824">

                                                            <div class="wpb_wrapper">

                                                                <div class="empty-space marg-lg-b15"></div>

                                                            </div>

                                                        </div>

                                                    </div>

                                                    <form class="dform" method="POST" action="email1.php">

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputEmail1">Name</label>

                                                            </div>

                                                            <div class="col-md-9">

                                                                <input type="text" name="dctr" class="form-control" id="exampleInputEmail1" placeholder="Enter Your Name"> </div>

                                                        </div>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">Contact No.</label>

                                                            </div>

                                                            <div class="col-md-9">

                                                                <input name="cnt" type="text" class="form-control" id="exampleInputPassword1" placeholder="Contact Number"> </div>

                                                        </div>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">Email</label>

                                                            </div>

                                                            <div class="col-md-9">

                                                                <input name="email" type="text" class="form-control" id="exampleInputPassword1" placeholder="Enter Your Email"> </div>

                                                        </div>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">Reason </label>

                                                            </div>

                                                            <div class="col-md-9">

                                                                <input name="rsn" type="text" class="form-control" id="exampleInputPassword1" placeholder="Reason for Appointment"> </div>

                                                        </div>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">Doctor</label>

                                                            </div>

                                                            <div class="col-md-9">

                                                                <select name="dctrname" class="form-control " placeholder="Select Doctor">

                                                                    <option>Dr. Abdul Sattar Dbeis <small>(Orthodontist)</small></option>

                                                                    <option>Dr.Razan Al Kubaisi <small>(G.P Dentist)</small></option>

                                                                    <option>Dr.Khader sh.saleh <small>(G.P Dentist)</small></option>

                                                                    <option>Dr. Naseeb Khudair <small>(G.P Dentist)</small></option>

                                                                    <option>Dr.Satyanarayanareddy <small>(Orthodontist)</small></option>

                                                                    <option>Dr.Waseem <small>(Physiotherapist)</small></option>

                                                                    <option>Horea Mohammed All Maharmeh <small>(Occupational Therapist)</small></option>

                                                                </select>

                                                            </div>

                                                        </div>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">Date</label>

                                                            </div>

                                                            <div class=" col-md-9">

                                                                <div class='input-group date'>

                                                                    <input name="date" type='Date' class="form-control" placeholder="Appointment Date" id='datetimepicker4' /> <span class="input-group-addon">

                         <span class="glyphicon glyphicon-calendar"></span> </span>

                                                                </div>

                                                            </div>

                                                        </div>

                                                        <script type="text/javascript">

                                                            $(function () {

                                                                $('#datetimepicker4').datetimepicker();

                                                            });

                                                        </script>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">Do u Have Insurance</label>

                                                            </div>

                                                            <div class="col-md-4">

                                                                <select name="ins" class="form-control ">

                                                                    <option>Yes</option>

                                                                    <option>No</option>

                                                                </select>

                                                            </div>

                                                            <div class="col-md-5">

                                                                <input name="ins1" type="text" class="form-control" id="exampleInputPassword1" placeholder="Select Insurence"> </div>

                                                        </div>

                                                        <div class="form-group row">

                                                            <div class="col-md-3">

                                                                <label for="exampleInputPassword1">New Patient ?</label>

                                                            </div>

                                                            <div class="col-md-4">

                                                                <select name="newp" class="form-control ">

                                                                    <option>Yes</option>

                                                                    <option>No</option>

                                                                </select>

                                                            </div>

                                                            <div class="col-md-5">

                                                                <input name="regno" type="text" class="form-control" id="exampleInputPassword1" placeholder="register number"> </div>

                                                        </div>

                                                        <div class="btcls">

                                                            <div class="c-btn input">

                                                                <input type="submit" value="submit now" class="wpcf7-form-control wpcf7-submit"><span class="ajax-loader"></span> </div>

                                                        </div>

                                                    </form>

                                                </div>

                                            </div>

                                        </div>

                                    </div>

                                </div>

                            </div>

                        </div>

                    </div>

                </div>

            </div>

        </div>

    </div>

      <!--.content_wrapper-->
   <?php include "footer.php";?>
        </div>
        <div id="btt"><i class="fa fa-angle-double-up"></i></div>
        <script type="text/javascript">
            (function () {
                function addEventListener(element, event, handler) {
                    if (element.addEventListener) {
                        element.addEventListener(event, handler, false);
                    }
                    else if (element.attachEvent) {
                        element.attachEvent('on' + event, handler);
                    }
                }

                function maybePrefixUrlField() {
                    if (this.value.trim() !== '' && this.value.indexOf('http') !== 0) {
                        this.value = "http://" + this.value;
                    }
                }
                var urlFields = document.querySelectorAll('.mc4wp-form input[type="url"]');
                if (urlFields && urlFields.length > 0) {
                    for (var j = 0; j < urlFields.length; j++) {
                        addEventListener(urlFields[j], 'blur', maybePrefixUrlField);
                    }
                } /* test if browser supports date fields */
                var testInput = document.createElement('input');
                testInput.setAttribute('type', 'date');
                if (testInput.type !== 'date') {
                    /* add placeholder & pattern to all date fields */
                    var dateFields = document.querySelectorAll('.mc4wp-form input[type="date"]');
                    for (var i = 0; i < dateFields.length; i++) {
                        if (!dateFields[i].placeholder) {
                            dateFields[i].placeholder = 'YYYY-MM-DD';
                        }
                        if (!dateFields[i].pattern) {
                            dateFields[i].pattern = '[0-9]{4}-(0[1-9]|1[012])-(0[1-9]|1[0-9]|2[0-9]|3[01])';
                        }
                    }
                }
            })();
        </script>
       
        <!--[if lte IE 9]>
<script type='text/javascript' src='http://demos.pixelatethemes.com/dentalcarelst/wp-content/plugins/mailchimp-for-wp/assets/js/third-party/placeholders.min.js?ver=4.1.6'></script>
<![endif]-->
        </body>

        </html>