PK
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<div id="layout">
<div id="bodycontainer">
<div id="leftcontainer">
<div id="welcomezone">
<h1>Welcome To Urology Solution</h1>
<div style="padding:10px 0 10px 0">
<div id="contact_form"> <br>
<h6>Appointment Form:</h6>
<form method="post" name="contact" id="contact_form">
<table width="97%">
<tbody>
<tr>
<label for="name" id="name_label">
<td class="body" align="left" valign="top"><strong>Full Name:</strong> *</td></label>
<td align="left" valign="top">
<input name="name"id ="name" size="30" type="text"></td>
<td><label style="display: none;" class="error" for="name" id="name_error"><b>Name is required.</b></label></td>
</tr>
<tr>
<label for="age" id="age_label">
<td class="body" align="left" valign="top"><strong>Age: </strong> *</td></label>
<td align="left" valign="top">
<input name="age" id="age" size="30" type="text" onKeyPress="return isNumberKey(event)" maxlength="3"></td>
<td><label style="display: none;" class="error" for="age" id="age_error"><b>Age is required.</b></label></td>
</tr>
<tr>
<label for="gender" id="gender_label">
<td class="body" align="left" valign="top"><strong>Gender: </strong> </td></label>
<td align="left" valign="top">
Male:<input name="gender" id="gender" value="male" type="radio" checked="checked">
Female:<input name="gender" value="female" type="radio" id="gender1">
</td>
<td><label style="display: none;" class="error" for="gender" id="gender_error"><b>Gender is required.</b></label>
<!--<label style="display: none;" class="error" for="gender1" id="gender_error1"><b>Gender is required.</b></label>-->
</td>
</tr>
<tr>
<label for="phone" id="phone_label">
<td class="body" align="left" valign="top"><strong> Phone: </strong> *</td></label>
<td align="left" valign="top">
<input name="phone" id="phone" size="30" type="text" onKeyPress="return isNumberKey(event)" maxlength="10"></td>
<td><label style="display: none;" class="error" for="phone" id="phone_error"><b>Phone is required.</b></label></td>
</tr>
<tr>
<label for="email" id="email_label">
<td class="body" align="left" valign="top"><strong> Email: </strong> *</td></label>
<td align="left" valign="top">
<input name="email"id="email" size="30" type="text"></td>
<td> <label style="display: none;" class="error" for="email" id="email_error"><b>Email is required.</b></label>
<label style="display: none;" class="error" for="email" id="email_error1"><b>Valid Email-Id is required.</b></label></td>
</tr>
<tr>
<label for="symptoms" id="symptoms_label">
<td class="body" align="left" valign="top"><strong>Symptoms in Brief : </strong> *</td></label>
<td align="left" valign="top">
<textarea name="symptoms"id="symptoms" cols="25" rows="6"></textarea></td>
<td><label style="display: none;" class="error" for="symptoms" id="symptoms_error"><b>Symptoms is required.</b></label></td>
</tr>
<tr>
<label for="timings" id="timings_label">
<td class="body" align="left" valign="top"><strong>Preferred timings: </strong> *</td></label>
<td align="left" valign="top">
<select name="timings" id="timings" style="height:29px;">
<optgroup label="Monday - Friday">
<option value="" selected="selected">please select your preferred time</option>
<option value="18:00 - 18:30">18:00 - 18:30</option>
<option value="18:30 - 19:00">18:30 - 19:00</option>
<option value="19:00 - 19:30">19:00 - 19:30</option>
<option value="19:30 - 20:00">19:30 - 20:00</option>
<option value="20:00 - 20:30">20:00 - 20:30</option>
<option value="20:30 - 21:00">20:30 - 21:00</option>
<option value="21:00 - 21:30">21:00 - 21:30</option>
<option value="21:30 - 22:00">21:30 - 22:00</option>
<option value="22:00 - 22:30">22:00 - 22:30</option>
<option value="22:30 - 23:00">22:30 - 23:00</option>
</optgroup><optgroup label="Sunday">
<option value="08:00 - 08:30">08:00 - 08:30</option>
<option value="08:30 - 09:00">08:30 - 09:00</option>
<option value="09:00 - 09:30">09:00 - 09:30</option>
<option value="09:30 - 10:00">09:30 - 10:00</option>
<option value="10:00 - 10:30">10:00 - 10:30</option>
<option value="10:30 - 11:00">10:30 - 11:00</option>
</optgroup></select></td>
<td> <label style="display: none;" class="error" for="timings" id="timings_error"><b>Timings is required.</b></label></td>
</tr>
<tr>
<label for="datetime" id="datetime_label">
<td class="body" align="left" valign="top"><strong>Specific Date:</strong> *</td></label>
<td align="left" valign="top">
<input id="popup_container" name="datetime" readonly="readonly" style="cursor: text; float:left" size="9"/>
<!--<input name="datetime"id ="datetime" size="30" type="text">--></td>
<td><label style="display: none;" class="error" for="datetime" id="datetime_error"><b>Specific Date & Time is required.</b></label></td>
</tr>
<tr>
<td></td>
<td><input name="Sub" class="button" value="Fix Appointment" id="sub" type="button"></td>
</tr>
</tbody></table>
</form>
</div>
<!--<div> <br>
<h6>Contact Information: </h6>
<img src="images/excellentcare.jpg"alt="" class="project-img" height="100" width="152" />Excellent Care Hospital</br>
No 7/14, Near Univercell Show Room,</br>
7th Cross Steet Rajalakshmi Nagar,</br>
100 Feet Byepass Road,</br>
Velachery , Chennai</br>
India , PIN:600042</br>
TEL : +91 9791014797</br>
Email : <u>drknatarajan@yahoo.co.in</u><br>
<p> <span><img src="images/ico-phone.png" alt="Phone" height="16" hspace="2" width="20"> Phone:</span> +91 9791014797<br>
<span><img src="images/ico-fax.png" alt="Fax" height="16" hspace="2" width="20"> Fax:</span> (888) 987 654 321<br>
<span><img src="images/ico-website.png" alt="WWW Link" height="16" hspace="2" width="20"> Website:</span> <a href="http://urologysolution.com/">www.urologysolution.com</a><br>
<span><img src="images/ico-email.png" alt="Email" height="16" hspace="2" width="20"> Email:</span> <a href="mailto:drknatarajan@yahoo.co.in">drknatarajan@yahoo.co.in</a><br>
<span><img src="images/ico-twitter.png" alt="Twitter Follow" height="16" hspace="3" width="20"> <a href="#">Follow</a> on Twitter</span>
<br><br>
</p>
</div>-->
</div>
</div>
</div>
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include('sidebar.php');
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PK 99