File: /home/imensosw/www/imenso.co/dev/prc/contact.html
<!doctype html>
<html lang="en-US" >
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="profile" href="http://gmpg.org/xfn/11">
<title>Patient Portal</title>
<link rel='stylesheet' href='css/bootstrap.min.css' media='all' />
<link rel='stylesheet' href='css/style-2.css' media='all' />
<link rel='stylesheet' href='css/responsive.css' media='all' />
<link rel='stylesheet' href='css/chosen.css' media='all' />
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.css" media="all">
<script src="js/jquery.min.js"></script>
<script src="js/bootstrap.min.js"></script>
<script src="js/popover.js"></script>
<!-- <script src="js/popper.min.js" integrity="sha384-b/U6ypiBEHpOf/4+1nzFpr53nxSS+GLCkfwBdFNTxtclqqenISfwAzpKaMNFNmj4" crossorigin="anonymous"></script> -->
<script src="js/chosen.jquery.js"></script>
<script>
$(function(){
$("#includedContent").load("sidebar.html");
$('.sidebar_nav a').removeClass('active');
$('.sidebar_nav a').eq(1).addClass('active');
});
</script>
</head>
<body style="background: #F0F4F7;">
<div class="container-fluid">
<div id="includedContent"></div>
<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>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
</div><!--/row-->
</div>
</div>
<script type="text/javascript">
$(function(){
$(".chosen").chosen();
});
</script>
</body>
</html>