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<style> .modal{ z-index: 99999; } .modal-header { background: #000b57; color: #fff; justify-content: center; padding:10px; } .modal-title { color:#fff; font-size: 16px; } .modal-header .close { position: absolute; right: 15px; top: 16px; color: #fff; opacity: 1; padding: 10px; } .modal-body .form-control { margin-bottom: 15px; } .btn-submit { background-color: #000b57; border: none; width: 100%; font-size: 16px; padding: 10px; color: #fff; } .btn-submit:hover { background-color: #000b57; } .modal-backdrop { z-index:99 } .modal-lg { max-width:400px; } .form-group { margin-bottom:0; } .form-control { font-size:13px; } </style> <!-- Modal --> <div class="modal fade" id="appointmentModal" tabindex="-1" role="dialog" aria-labelledby="appointmentModalLabel" aria-hidden="true"> <div class="modal-dialog modal-lg" role="document"> <div class="modal-content"> <!-- Header --> <div class="modal-header"> <h5 class="modal-title" id="appointmentModalLabel">BOOK AN APPOINTMENT</h5> <button type="button" class="close" data-dismiss="modal" aria-label="Close"> <span aria-hidden="true">×</span> </button> </div> <!-- Body --> <div class="modal-body"> <form action="appointment.php" method="post"> <div class="form-row"> <div class="form-group col-md-6"> <input type="text" class="form-control" name="firstname" placeholder="First Name *" required pattern="^(?!\s*$).+" title="Name cannot be empty or contain only spaces"> </div> <div class="form-group col-md-6"> <input type="text" class="form-control" name="mobile" placeholder="Mobile No. *" required="" required pattern="^(?!\s*$).+" title="phone cannot be empty or contain only spaces"> </div> </div> <div class="form-row"> <div class="form-group col-md-6"> <select class="form-control" name="city" required> <option value="">Select City *</option> <option>Rudrapur</option> </select> </div> <div class="form-group col-md-6"> <select class="form-control" name="clinic" required> <option value="">Dental Clinic *</option> <option>Guru Maa Advanced Dental Care</option> </select> </div> </div> <div class="form-row"> <div class="form-group col-md-6"> <select class="form-control" name="speciality" required> <option value="">Select Speciality *</option> <option>Prosthodontist</option> <option>Orthodontist</option> <option>Implantologist</option> <option>Maxillofacial Surgeon</option> <option>Oral Surgeon</option> <option>Periodontist</option> </select> </div> <div class="form-group col-md-6"> <select class="form-control" name="doctor" required> <option value="">Select Doctor *</option> <option>Dr. Aanchal Dhingrah</option> <option>Dr. Karan Bhalla</option> <option>Dr. Abhay Lamba</option> <option>Dr. Himani Yadav</option> <option>Dr. Anishree</option> <option>Dr. Manish Shukla</option> <option>Dr. Mansi Bansal</option> </select> </div> </div> <div class="form-group"> <input type="date" class="form-control" name="appointment_date" required> </div> <button type="submit" class="btn-submit">Submit</button> </form> </div> </div> </div> </div>
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