File: /home/imensosw/www/imenso.co/dev/mps-new/contact.html
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<title>Patient Portal</title>
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<body style="background: #F0F4F7;">
<div class="container-fluid">
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<div class="right right_panel animate dashboard">
<div class="m-5">
<div class="container-fluid">
<div class="row payment_code mb-5">
<div class="col-md-12 mb-3 header_area">
<div class="d-flex justify-content-between align-items-center">
<h4 calss="mb-0">Contact Us</h4>
</div>
<hr />
</div>
<div class="col-md-12">
<div class="form-wrapper">
<form class="">
<div class="row">
<div class="col-lg-8">
<div class="row">
<div class="col-md-6">
<div class="form-group">
<label for="">Your Name*</label>
<input type="text" aria-describedby="emailHelp" id="" class="form-control">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="">Provide a valid e-mail to respond to*</label>
<input type="text" id="" class="form-control">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="">Please enter your ten-digit phone number</label>
<input type="text" id="" class="form-control">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="">Patient Name*</label>
<input type="text" id="" class="form-control">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="">Patient Date of Birth: (mm/dd/yyyy)*</label>
<input type="text" id="" class="form-control">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="">Your Relationship to Patient*</label>
<input type="text" id="" class="form-control">
</div>
</div>
<div class="col-md-12">
<div class="form-group">
<label for="">Please select a topic that most closely relates to your issue*</label>
<!-- <input type="text" id="" class="form-control"> -->
<select class="chosen form-control" name="faculty">
<option value="-Select-">-Select-</option>
<option value="Payment/Payment Plan">Payment/Payment Plan</option>
<option value="Insurance">Insurance</option>
<option value="Discount/Financial Assistance">Discount/Financial Assistance</option>
<option value="Charges">Charges</option>
<option value="Other">Other</option>
</select>
</div>
</div>
</div>
</div>
<div class="col-lg-4">
<div class="row">
<div class="col-md-12">
<label>Please provide a description of your issue</label>
<textarea rows="7" class="form-control"></textarea>
<a href="" class="btn btn-login btn-block" style="margin-top: 35px;">Submit</a>
<p class="mt-2 text-center"><small>Click to Submit an E-mail to our Support Center</small></p>
</div>
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</form>
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