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reservation.php
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reservation.php
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<!DOCTYPE html>
<html lang="en">
<!-- Basic -->
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<!-- Mobile Metas -->
<meta name="viewport" content="width=device-width, initial-scale=1">
<meta name="viewport" content="initial-scale=1, maximum-scale=1">
<!-- Site Metas -->
<title>Life Line</title>
<meta name="keywords" content="">
<meta name="description" content="">
<meta name="author" content="">
<!-- Site Icons -->
<link rel="shortcut icon" href="images/fevicon.ico.png" type="image/x-icon" />
<link rel="apple-touch-icon" href="images/apple-touch-icon.png">
<!-- Bootstrap CSS -->
<link rel="stylesheet" href="css/bootstrap.min.css">
<!-- Site CSS -->
<link rel="stylesheet" href="style.css">
<!-- Colors CSS -->
<link rel="stylesheet" href="css/colors.css">
<!-- ALL VERSION CSS -->
<link rel="stylesheet" href="css/versions.css">
<!-- Responsive CSS -->
<link rel="stylesheet" href="css/responsive.css">
<!-- Custom CSS -->
<link rel="stylesheet" href="css/custom.css">
<!-- Modernizer for Portfolio -->
<script src="js/modernizer.js"></script>
<!-- [if lt IE 9] -->
</head>
<body class="clinic_version">
<!-- LOADER -->
<div id="preloader">
<img class="preloader" src="images/loaders/heart-loading2.gif" alt="">
</div>
<!-- END LOADER -->
<header>
<div class="header-top wow fadeIn">
<div class="container">
<a class="navbar-brand" href="index.php"><img src="images/logo1.png" alt="image"></a>
<div class="right-header">
<div class="header-info">
<div class="info-inner">
<span class="icontop"><img src="images/phone-icon.png" alt="#"></span>
<span class="iconcont"><a href="tel:800 123 456">+914828-224042</a></span>
</div>
<div class="info-inner">
<span class="icontop"><i class="fa fa-envelope" aria-hidden="true"></i></span>
<span class="iconcont"><a data-scroll href="mailto:info@yoursite.com">info@Lifeline.com</a></span>
</div>
<div class="info-inner">
<span class="icontop"><i class="fa fa-clock-o" aria-hidden="true"></i></span>
<span class="iconcont"><a data-scroll href="#">Daily: 7:00am - 8:00pm</a></span>
</div>
</div>
</div>
</div>
</div>
<div class="header-bottom wow fadeIn">
<div class="container">
<nav class="main-menu">
<div class="navbar-header">
<button type="button" class="navbar-toggle collapsed" data-toggle="collapse" data-target="#navbar" aria-expanded="false" aria-controls="navbar"><i class="fa fa-bars" aria-hidden="true"></i></button>
</div>
<div id="navbar" class="navbar-collapse collapse">
<ul class="nav navbar-nav">
<li><a class="active" href="index.php">Home</a></li>
</ul>
</div>
</nav>
</div>
</div>
<div id="service" class="services wow fadeIn">
<div class="col-lg-4 col-md-4 col-sm-6 col-xs-12">
<div class="appointment-form">
<h3><span>+</span> Book Appointment</h3>
<div class="form">
<form method="post" action="connection.php">
<fieldset>
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="row">
<div class="form-group">
<input type="text" id="name" name="name" placeholder="Your Name" />
</div>
</div>
</div>
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="row">
<div class="form-group">
<input type="number" id="phone" name="phone" placeholder="phone" />
</div>
</div>
</div>
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="row">
<div class="form-group">
<input type="date" id="day" name="day" placeholder="Date" />
</div>
</div>
</div>
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12 select-section">
<div class="row">
<div class="form-group">
<!-- <label><br />State</label> -->
<select data-target="secondList" class="firstList selectFilter" name="state">
<option value="-1">State</option>
<option data-ref="one" >Andra Pradesh</option>
<option data-ref="two" >Delhi</option>
<option data-ref="three">Karnataka</option>
<option data-ref="four">Kerala</option>
<option data-ref="five">Punjab</option>
<option data-ref="six">Tamil Nadu</option>
</select>
<!-- <label><br />District</label> -->
<select data-target="thirdList" class="secondList selectFilter" name="district">
<option value="-1">District</option>
<option data-ref="A" data-belong="four" >Alapuzha</option>
<option data-ref="B" data-belong="four">Eranakulam</option>
<option data-ref="C" data-belong="four">Idukki</option>
<option data-ref="D" data-belong="four">Kannur</option>
<option data-ref="E" data-belong="four">Kasaragod</option>
<option data-ref="F" data-belong="four">Kottayam</option>
<option data-ref="G" data-belong="four">Kollam</option>
<option data-ref="H" data-belong="four">Kozhikode</option>
<option data-ref="I" data-belong="four">Malappuram</option>
<option data-ref="J" data-belong="four">Palakkad</option>
<option data-ref="K" data-belong="four">Pathanamthitta</option>
<option data-ref="L" data-belong="four">Trivandrum</option>
<option data-ref="M" data-belong="four">Thrissur</option>
<option data-ref="N" data-belong="four">Wayanad</option>
</select>
<!-- <label><br />Hospital</label> -->
<select data-target="forthList" class="thirdList selectFilter" name="hospital">
<option value="-1">Hospitals</option>
<option data-belong="A">GOVERNMENT T.D. Medical College Hospital, Alappuzha</option>
<option data-belong="B">Government Medical College Eranakulam</option>
<option data-belong="C">Government Medical College Idukki</option>
<option data-belong="D">Government Medical College Kannur</option>
<option data-belong="E">Government Medical College Kasaragod</option>
<option data-belong="F">Government Medical College Hospital, Kottayam</option>
<option data-belong="G">Government Medical College Kollam</option>
<option data-belong="H">Government Medical College Hospital, Kozhikode</option>
<option data-belong="I">Government Medical College Hospital, Malappuram</option>
<option data-belong="J">Government Medical College Hospital, Palakkad</option>
<option data-belong="K">Government Medical College Hospital, Pathanamthitta</option>
<option data-belong="L">Government Medical College Hospital, Trivandrum</option>
<option data-belong="M">Government Medical College Hospital, Thrissur</option>
<option data-belong="N">Government Medical College Hospital, Wayanad</option>
<option data-belong="F">Pushpagiri Medical College Hospital, Thiruvalla</option>
<option data-belong="F">Mar sleeva Medicity, Pala</option>
<option data-belong="F">Maryqueens Hospital, Kanjirappally </option>
<option data-belong="B">Apollo Adlux Hospital, Angamaly</option>
<option data-belong="B">VPS Lakeshore Hospital, Kochi</option>
</select>
</div>
</div>
</div>
<!-- <div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="row">
<div class="form-group">
<select class="form-control" name="docname">
<option>Doctor Name</option>
<option>Mr.Rejin Joseph - Cardiac</option>
<option>Mrs. Arathy Prathap- Orthology</option>
<option>Mrs. Akasha Joshy - Neurology</option>
<option>Mrs. Akshatha K - Traumotology</option>
<option>Mrs. Asha Sarath - For disabled</option>
<option>Mr. Kevin K - Pulmonary</option>
<option>Mr. Ajai Manuel - Gynaecology</option>
<option>Mr. Ashik John - Dental</option>
<option>Mrs. Miya George - Nephrology</option>
</select>
</div>
</div>
</div> -->
<!-- <div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="row">
<div class="form-group">
<textarea rows="4" id="textarea_message" class="form-control" name="msg" placeholder="Your Message..."></textarea>
</div>
</div>
</div> -->
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="row">
<div class="form-group">
<div class="center"><button type="submit">Submit</button></div>
</div>
</div>
</div>
</fieldset>
</form>
</div>
</div>
</div>
<div class="container">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-6 col-xs-12">
<div class="inner-services">
<div class="col-lg-4 col-md-6 col-sm-6 col-xs-12">
<div class="serv">
<span class="icon-service"><img src="images/service-icon1.png" alt="#" /></span>
<h4>PREMIUM FACILITIES</h4>
<p>Only the best facilities for the best treatment.</p>
</div>
</div>
<div class="col-lg-4 col-md-6 col-sm-6 col-xs-12">
<div class="serv">
<span class="icon-service"><img src="images/service-icon2.png" alt="#" /></span>
<h4>LARGE LABORATORY</h4>
<p>A large laboratory for fast and efficient results.</p>
</div>
</div>
<div class="col-lg-4 col-md-6 col-sm-6 col-xs-12">
<div class="serv">
<span class="icon-service"><img src="images/service-icon3.png" alt="#" /></span>
<h4>DETAILED SPECIALIST</h4>
<p>The best specialists all over the world is here.</p>
</div>
</div>
<div class="col-lg-4 col-md-6 col-sm-6 col-xs-12">
<div class="serv">
<span class="icon-service"><img src="images/service-icon4.png" alt="#" /></span>
<h4>CHILDREN CARE CENTER</h4>
<p>High level industry standard care system dedicated for children.</p>
</div>
</div>
<div class="col-lg-4 col-md-6 col-sm-6 col-xs-12">
<div class="serv">
<span class="icon-service"><img src="images/service-icon5.png" alt="#" /></span>
<h4>FINE INFRASTRUCTURE</h4>
<p>Eco-friendly infrasture.We make use of the renewable energy for a healthier future.</p>
</div>
</div>
<div class="col-lg-4 col-md-6 col-sm-6 col-xs-12">
<div class="serv">
<span class="icon-service"><img src="images/service-icon6.png" alt="#" /></span>
<h4>ANYTIME BLOOD BANK</h4>
<p>24/7 bloodbank available.</p>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<!-- end section -->
<!-- end copyrights -->
<a href="#home" data-scroll class="dmtop global-radius"><i class="fa fa-angle-up"></i></a>
<!-- all js files -->
<script src="js/all.js"></script>
<!-- all plugins -->
<script src="js/custom.js"></script>
<!-- map -->
<script src="js/selectFilter.min.js"></script>
</body>
</html>