File: /home/imensosw/www/imenso.co/dev/prc/index-3.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="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.css" media="all">
</head>
<body>
<section class="banner5 banner7">
<div class="container-fluid">
<div class="row">
<div class="col-md-4">
</div>
<div class="col-md-8">
<div role="document" class="modal-dialog">
<div class="modal-content">
<div class="modal-body">
<div class="container-fluid">
<div class="row d-flex align-items-center">
<div class="col-md-12 mb-5">
<img class="ml-5 mb-5" src="images/mps-logo.png" width="130">
<h4 class="ml-5">Pay Hospital Bill</h4></div>
<div class="col-md-6 border-right">
<form class="px-5" id="form-1">
<div class="pay-bill-fields">
<div class="form-group">
<label for="">Payment Code from recent Statement:<a href="javascript:;" data-toggle="modal" data-target="#paymentCode"> (Whats's this?)</a></label>
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="e.g. 14##########">
</div>
<div class="form-group">
<label for="">Last Name as it appears on Statement:</label>
<input type="text" class="form-control" id="" placeholder="e.g. Lee">
</div>
</div>
<div class="login-fields" style="display: none;">
<div class="form-group">
<label for="">E-mail Address</label>
<input type="email" class="form-control" id="" aria-describedby="emailHelp" placeholder="Enter your e-mail">
</div>
<div class="form-group">
<label for="">Password</label>
<input type="text" class="form-control" id="" placeholder="Enter your password">
</div>
</div>
<div class="mt-5 d-flex justify-content-between">
<button type="button" class="pay-bill btn btn-primary">Pay Bill</button>
<button type="button" class="ml-2 login btn btn-flat">Login</button>
</div>
</form>
<form class="px-5" id="form-2" style="display: none;">
<div class="form-group">
<label for="">Payment Code from recent Statement:<a href="javascript:;" data-toggle="modal" data-target="#paymentCode"> (Whats's this?)</a></label>
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="Payment Code e.g. 14##########">
</div>
<div class="form-group">
<label for="">Last Name as it appears on Statement:</label>
<input type="text" class="form-control" id="" placeholder="Last Name as it appears on Statement">
</div>
<div class="form-group">
<label for="">E-mail Address</label>
<input type="email" class="form-control" id="" aria-describedby="emailHelp" placeholder="Enter your e-mail">
</div>
<div class="form-group">
<label for="">Date of Birth (Optional)</label>
<input type="text" class="form-control" id="" placeholder="Date of Birth">
</div>
<div class="mt-5 d-flex justify-content-between">
<button type="button" class="btn btn-primary">Submit</button>
</div>
</form>
</div>
<div class="col-md-6">
<div class="px-5">
<div class="reg-ben">
<h5>Registration Benefits</h5>
<ul class="bullets">
<li><i class="fa fa-check"></i> Login with your e-mail address</li>
<li><i class="fa fa-check"></i> Sign-up for e-Statements</li>
<li><i class="fa fa-check"></i> Link Multiple Accounts</li>
<li><i class="fa fa-check"></i> View Account Ledger</li>
</ul>
<a href="javascript:;" class="btn register btn-secondary mt-3">Register Now</a>
</div>
<div class="reg-cta" style="display: none;">
<a href="" class="btn-block btn btn-login">Pay Bill</a>
<a href="" class="btn-block btn mt-4 btn-secondary">Login</a>
</div>
</div>
</div>
</div>
</div>
</div> <!--/modal-body-->
<div class="modal-footer text-left">
<div class="ml-5 mt-2">
<p>To make a payment by phone, please dial <a href="tel:1-855-829-0149">1-855-829-0149</a> (Payment Code required)</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<div class="modal fade" id="paymentCode" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Payment Code</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<img src="images/code.png" class="img-fluid">
</div>
</div>
</div>
</div>
<nav class="fab">
<a href="#" class="buttons" tooltip="E-mail Us"></a>
<a href="#" class="buttons" tooltip="Commonly Asked Questions"></a>
<a class="buttons" tooltip="Chat Now" href="#"></a>
</nav>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.12.4/jquery.min.js"></script>
<script src="js/bootstrap.min.js"></script>
<script type="text/javascript">
$( ".login" ).click(function() {
$(this).addClass('btn-primary');
$(this).removeClass('btn-flat');
$('.pay-bill').removeClass('btn-primary');
$('.pay-bill').addClass('btn-flat');
$('.login-fields').show();
$('.pay-bill-fields').hide();
});
$( ".pay-bill" ).click(function() {
$(this).addClass('btn-primary');
$(this).removeClass('btn-flat');
$('.login').removeClass('btn-primary');
$('.login').addClass('btn-flat');
$('.login-fields').hide();
$('.pay-bill-fields').show();
});
$( ".register" ).click(function() {
$('#form-1').hide();
$('#form-2').show();
$('.reg-ben').hide();
$('.reg-cta').show();
});
</script>
</body>
</html>