File: /var/www/html/wpcurated/wp-content/themes/curatedbkk/page-refer-a-patient.php
<?php /* Template Name: Refer a patient Page */
get_header();
?>
<section class="sub-bnr intake-form-bnr referal-main-bnr">
<div class="container custom-container">
<div class="content-area">
<div class="title">Refer A <span>Patient</span></div>
<div class="sub-para">Odio cras proin proin sit quis fringilla aliquet. Consectetur elementum viverra egestas egestas nulla ullamcorper varius quam.</div>
</div>
<!-- <div class="bnr-img women-img">
<img src="<?php echo get_template_directory_uri(); ?>/img/women.png" alt="women">
</div> -->
</div>
<div class="bnt-txt-btm">
<img src="<?php echo get_template_directory_uri(); ?>/img/service-detail-bnr-txt.png" alt="">
</div>
</section>
<section class="intake-form-sec refer-form">
<div class="container custom-container">
<form class="intake-form-wrapper" data-parsley-validate>
<div class="row">
<div class="form-group col-md-6">
<label for="full-name" class="form-label">Full Name <span>*</span></label>
<input type="text" id="full-name" class="form-control" name="full_name" required placeholder="Enter Full Name" data-parsley-required="true" data-parsley-error-message="Name is required.">
</div>
<div class="form-group col-md-6">
<label for="contact-number" class="form-label">Contact Number <span>*</span></label>
<input type="tel" id="contact-number" class="form-control" name="contact_number" required placeholder="Enter Contact Number"
pattern="^[0-9]{10}$"
title="Please enter a valid 10-digit contact number." data-parsley-pattern="^[0-9]{10}$"
data-parsley-required="true" data-parsley-error-message="Please enter a valid 10-digit contact number.">
</div>
<div class="form-group col-md-6">
<label for="email-id" class="form-label">Mail ID <span>*</span></label>
<input type="email" id="email-id" class="form-control" name="email_id" required placeholder="Enter Mail ID"
data-parsley-type="email" data-parsley-required="true"
data-parsley-error-message="Please enter a valid email address.">
</div>
<div class="form-group col-md-6">
<label for="reason-referral" class="form-label">Reason for Referral <span>*</span></label>
<input type="text" id="reason-referral" class="form-control" name="reason_referral" required placeholder="Enter Reason" data-parsley-required="true" data-parsley-error-message="Reason for referral is required">
</div>
</div>
<div class="row">
<div class="col-12">
<label for="description" class="form-label">Description <span>*</span></label>
<textarea id="description" class="form-control" name="description" rows="4" placeholder="Enter The Patient's Description"
data-parsley-required="true" data-parsley-error-message="Description is required."></textarea>
</div>
</div>
<div class="btn-blk btn-blk-refer">
<div id="successAlert" class="alert alert-success" role="alert" style="text-align: center;display:none;"></div>
<div id="dangerAlert" class="alert alert-danger" role="alert" style="text-align: center;display:none;"></div>
<div class="btn-sec">
<button type="button" class="primary-btn btn-cancel">
<span>Cancel</span>
<span><img src="<?php echo get_template_directory_uri(); ?>/img/left-arrow1.svg"></span>
</button>
<button type="submit" class="primary-btn btn-submit">
<span>Next</span>
<span><img src="<?php echo get_template_directory_uri(); ?>/img/left-arrow1.svg"></span>
</button>
</div>
</div>
</form>
</div>
</section>
<section class="faq-sec">
<div class="container custom-container">
<div class="title-blk">
<div class="small-title-sec">FAQ</div>
<div class="title">Your Questions Answered</div>
</div>
<div class="faq-blk-wrp">
<div class="accordion" id="faqCollapse">
<div class="accordion-item">
<h2 class="accordion-header" >
<!-- <div class="count-round">
01
</div> -->
<button class="accordion-button" type="button" data-bs-toggle="collapse" data-bs-target="#faqCollapseOne" aria-expanded="true" aria-controls="collapseOne">
How can I schedule an appointment?
</button>
</h2>
<div id="faqCollapseOne" class="accordion-collapse collapse show" data-bs-parent="#faqCollapse">
<div class="accordion-body">
While our practice is specialized in delivering care for treatment-resistant anxiety and depression disorders, our multi-disciplinary team is well-versed in treating comorbid insomnia, attention deficit or PTSD disorders.
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#faqCollapseTwo" aria-expanded="false" aria-controls="collapseTwo">
Do you accept insurance?
</button>
</h2>
<div id="faqCollapseTwo" class="accordion-collapse collapse" data-bs-parent="#faqCollapse">
<div class="accordion-body">
<strong>This is the second item's accordion body.</strong>
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#faqCollapseThree" aria-expanded="false" aria-controls="collapseThree">
What types of payment do you accept?
</button>
</h2>
<div id="faqCollapseThree" class="accordion-collapse collapse" data-bs-parent="#faqCollapse">
<div class="accordion-body">
<strong>This is the third item's accordion body.</strong>
</div>
</div>
</div>
<div class="accordion-item">
<h2 class="accordion-header">
<button class="accordion-button collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#faqCollapseFour" aria-expanded="false" aria-controls="collapseFour">
Are your services confidential?
</button>
</h2>
<div id="faqCollapseFour" class="accordion-collapse collapse" data-bs-parent="#faqCollapse">
<div class="accordion-body">
<strong>This is the third item's accordion body.</strong>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section class="logo-slider-sec">
<div class="logo-slider">
<div class="logo-slide">
<div class="inner">
<img src="<?php echo get_template_directory_uri(); ?>/img/logo-1.svg" alt="">
</div>
</div>
<div class="logo-slide">
<div class="inner">
<img src="<?php echo get_template_directory_uri(); ?>/img/logo-2.svg" alt="">
</div>
</div>
<div class="logo-slide">
<div class="inner">
<img src="<?php echo get_template_directory_uri(); ?>/img/logo-3.svg" alt="">
</div>
</div>
<div class="logo-slide">
<div class="inner">
<img src="<?php echo get_template_directory_uri(); ?>/img/logo-4.svg" alt="">
</div>
</div>
</div>
</section>
<?php get_footer(); ?>