MINI MINI MANI MO
<?
session_start();
if($_SESSION["lang"] == "") $_SESSION["lang"] = "th" ;
?>
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<html dir="ltr" lang="en-US">
<head>
<meta http-equiv="content-type" content="text/html; charset=utf-8" />
<meta name="author" content="" />
<link rel="shortcut icon" href="images/favicon.ico" type="image/x-icon" />
<!-- Stylesheets
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<link href="http://fonts.googleapis.com/css?family=Lato:300,400,600,700|Montserrat:400,700|Crete+Round:400italic" rel="stylesheet" type="text/css" />
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<link rel="stylesheet" href="css/style.css" type="text/css" />
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<!-- Medical Demo Specific Stylesheet -->
<link rel="stylesheet" href="css/medical.css" type="text/css" />
<link rel="stylesheet" href="css/dark.css" type="text/css" />
<link rel="stylesheet" href="css/font-icons.css" type="text/css" />
<link rel="stylesheet" href="css/medical-icons.css" type="text/css" />
<link rel="stylesheet" href="css/animate.css" type="text/css" />
<link rel="stylesheet" href="css/magnific-popup.css" type="text/css" />
<link rel="stylesheet" href="css/fonts.css" type="text/css" />
<!-- components CSS -->
<link rel="stylesheet" href="css/components/datepicker.css" type="text/css" />
<link rel="stylesheet" href="css/components/timepicker.css" type="text/css" />
<link rel="stylesheet" href="css/components/daterangepicker.css" type="text/css" />
<link rel="stylesheet" href="css/components/bs-filestyle.css" type="text/css" />
<link rel="stylesheet" href="css/responsive.css" type="text/css" />
<meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1" />
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<script src="http://css3-mediaqueries-js.googlecode.com/svn/trunk/css3-mediaqueries.js"></script>
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<? include "include/titledata.php"; ?>
<link rel="stylesheet" href="css/colors.php?color=168c48" type="text/css" />
<title>Vibharam Hospital :: ปรึกษาแพทย์ออนไลน์ </title>
<style>
.form-control.error { border: 2px solid red; }
#primary-menu ul li#appoint > a { color:#FFF!important; font-weight: 600; }
.white-section label {
display: block;
margin-bottom: 15px;
}
.white-section select {
width:100%!important;
}
.white-section pre { margin-top: 15px; }
</style>
</head>
<body class="stretched">
<!-- Document Wrapper
============================================= -->
<div id="wrapper" class="clearfix">
<? include "header.php"; ?>
<!-- Page Title
============================================= -->
<section id="page-title">
<div class="container clearfix">
<ol class="breadcrumb">
<li><a href="#">Home</a></li>
<li>Talk to doctor </li>
</ol>
</div>
</section><!-- #page-title end -->
<!-- Content
============================================= -->
<section id="content" class=" nomargin nopadding" >
<div class="content-wrap">
<div class="container clearfix " >
<div id="booking" class="section common-height nomargin bottommargin-sm" style="background: url('images/section-bg.jpg') top center no-repeat; background-width:100%;">
<div class="input-daterange travel-date-group padding20 bottommargin-sm">
<h2>ตอบปัญหาสุขภาพ </h2>
<div class="col-md-6"><p>โรงพยาบาลวิภาราม ยินดีบริการให้คำปรึกษาเกี่ยวกับสุขภาพด้านต่างๆ เพียงกรอกข้อมูลส่วนบุคคลและคำถามที่ต้องการด้านล่าง ทีมแพทย์และบุคคลากรของเรา จะดูแลทุกคำถามเป็นอย่างดี </p>
</div>
<div class="clearfix"></div>
<form class="nomargin" id="template-medical-form" name="template-medical-form" action=" " method="post" >
<div class="col_one_third padding20 " style="background-color:#FFF;">
<div class="col_full">
<label for="template-medical-name">ชื่อ-นามสุกล: *</label>
<input type="text" id="input1[]" name="template-medical-name" class="form-control not-dark required" value="">
</div>
<div class="col_full">
<label for="template-medical-phone">เบอร์โทร:</label>
<input type="text" id="input2[]" name="template-medical-phone" class="form-control not-dark " value="">
</div>
<div class="col_full">
<label for="template-medical-email">อีเมล: *</label>
<input type="email" id="input3[]" name="template-medical-email" class="form-control not-dark required" value="">
</div>
<div class="col_full">
<label for="template-medical-appoint-date">วัน เดือน ปีเกิด:</label>
<input type="text" id="input4[]" class="sm-form-control daterange3" value="10/20/1984" />
</div>
<div class="col_full">
<label>ไฟล์แนบ: (jpg, csv, pdf, doc, docx)</label>
<input id="input-12" name="input12[]" type="file" multiple class="file-loading">
</div>
<div class="col_full">
<label for="template-medical-second-booking ">ยินดีรับข่าวสารทางอีเมล์: </label>
<label class=" notopmargin rightmargin-sm inline-block">
<input type="radio" name="template-medical-second-booking" value="yes" checked>
ใช่
</label>
<label class="notopmargin inline-block">
<input type="radio" name="template-medical-second-booking" value="no" >
ไม่ใช่
</label>
</div>
</div>
<div class="col_one_third padding20" style="background-color:#FFF;">
<!-- <div class="col_full white-section">
<label for="template-medical-name">สาขาทางการแพทย์:</label>
<select class="selectpicker show-tick not-dark required" style="width:100%">
<optgroup label="อายุรกรรม" >
<option> คลินิกอายุรกรรม</option>
<option> ศูนย์ศัลยกรรมกระดูกและข้อ</option>
<option> คลินิกทันตกรรม</option>
</optgroup>
<optgroup label="ศัลยกรรม">
<option> คลินิกอายุรกรรม</option>
<option> ศูนย์ศัลยกรรมกระดูกและข้อ</option>
<option> คลินิกทันตกรรม</option>
</optgroup>
<optgroup label="สูติ - นรีเวช">
<option> คลินิกอายุรกรรม</option>
<option> ศูนย์ศัลยกรรมกระดูกและข้อ</option>
<option> คลินิกทันตกรรม</option>
</optgroup>
</select>
</div> -->
<div class="col_full">
<label for="template-medical-name">คำถาม / หัวเรื่อง: *</label>
<input type="text" id="subject" name="template-medical-subject" class="form-control not-dark required" value="">
</div>
<div class="col_full">
<label for="template-medical-email ">รายละเอียดการเจ็บป่วย / อาการ: *</label>
<textarea id="template-medical-mess1" name="template-medical-mess1" class="form-control bg-danger required" cols="30" rows="3"></textarea>
</div>
<div class="col_full">
<label for="template-medical-second-booking ">ท่านรู้จักเว็บไซต์ของเราจาก: </label>
<input type="checkbox" id="know-vibharam" name="1" value="Search"> Search Engine <br>
<input type="checkbox" id="know-vibharam" name="2" value="website" > เว็บไซต์อื่นๆ สื่อออนไลน์ <br>
<input type="checkbox" id="know-vibharam" name="3" value="อีเมล" > อีเมล์และจดหมายข่าว <br>
<input type="checkbox" id="know-vibharam" name="4" value="friend" > ทราบจากเพื่อนหรือมีคนแนะนำ <br>
<input type="checkbox" id="know-vibharam" name="5" value="social-media" > สื่ออื่นๆ เช่น สิ่งพิมพ์ นิตยสาร โทรทัศน์ วิทยุ
</div>
<!--
<div class="col_full">
<label for="template-medical-email">รหัสความปลอดภัย: <img src="images/captcha.jpg" width="120" height="40"></label>
<input type="email" id="template-medical-ps" class="form-control required" value="">
</div> -->
<div class="col_full">
<script src="https://www.google.com/recaptcha/api.js" async defer></script>
<div class="g-recaptcha" data-sitekey="6LdS3S0UAAAAAKTx3lXUojlGUiGlE-4WEyt0qFlv"></div>
</div>
<div class="hidden"> <input type="text" name="template-medical-botcheck" value="" /></div>
<button class="button button-rounded button-dark btn-block topmargin-10" type="submit" value="submit">ส่งคำถาม</button>
</div>
</form>
</div>
</div>
<div class="clearfix"></div>
<div class="padding20 bg-info"><br>
<p> ** หมายเหตุ :</p>
<p> กรุณาใช้คำถามสุภาพและกรอกข้อมูลจริง </p>
</div>
</div>
</div>
</section> <!-- #content end -->
<? include "footer.php"; ?>
<!-- Bootstrap Select Plugin -->
<script type="text/javascript" src="js/components/bs-select.js"></script>
<link rel="stylesheet" href="css/components/bs-select.css" type="text/css" />
<!-- Select Splitter Plugin -->
<script type="text/javascript" src="js/components/selectsplitter.js"></script>
<!-- Date & Time Picker JS -->
<script type="text/javascript" src="js/components/moment.js"></script>
<script type="text/javascript" src="js/components/datepicker.js"></script>
<script type="text/javascript" src="js/components/timepicker.js"></script>
<!-- Include Date Range Picker -->
<script type="text/javascript" src="js/components/daterangepicker.js"></script>
<script type="text/javascript">
$(function() {
$('.travel-date-group .default').datepicker({
autoclose: true,
startDate: "today",
});
$('.travel-date-group .today').datepicker({
autoclose: true,
startDate: "today",
todayHighlight: true
});
$('.travel-date-group .past-enabled').datepicker({
autoclose: true,
});
$('.travel-date-group .format').datepicker({
autoclose: true,
format: "dd-mm-yyyy",
});
$('.travel-date-group .autoclose').datepicker();
$('.travel-date-group .disabled-week').datepicker({
autoclose: true,
daysOfWeekDisabled: "0"
});
$('.travel-date-group .highlighted-week').datepicker({
autoclose: true,
daysOfWeekHighlighted: "0"
});
$('.travel-date-group .mnth').datepicker({
autoclose: true,
minViewMode: 1,
format: "mm/yy"
});
$('.travel-date-group .multidate').datepicker({
multidate: true,
multidateSeparator: " , "
});
$('.travel-date-group .input-daterange').datepicker({
autoclose: true
});
$('.travel-date-group .inline-calendar').datepicker();
$('.datetimepicker').datetimepicker({
showClose: true
});
$('.datetimepicker1').datetimepicker({
format: 'LT',
showClose: true
});
$('.datetimepicker2').datetimepicker({
inline: true,
sideBySide: true
});
});
$(function() {
// .daterange1
$(".daterange1").daterangepicker({
"buttonClasses": "button button-rounded button-mini nomargin",
"applyClass": "button-color",
"cancelClass": "button-light"
});
// .daterange2
$(".daterange2").daterangepicker({
"opens": "center",
timePicker: true,
timePickerIncrement: 30,
locale: {
format: 'MM/DD/YYYY h:mm A'
},
"buttonClasses": "button button-rounded button-mini nomargin",
"applyClass": "button-color",
"cancelClass": "button-light"
});
// .daterange3
$(".daterange3").daterangepicker({
singleDatePicker: true,
showDropdowns: true
},
function(start, end, label) {
var years = moment().diff(start, 'years');
alert("You are " + years + " years old.");
});
// reportrange
function cb(start, end) {
$(".reportrange span").html(start.format('MMMM D, YYYY') + ' - ' + end.format('MMMM D, YYYY'));
}
cb(moment().subtract(29, 'days'), moment());
$(".reportrange").daterangepicker({
"buttonClasses": "button button-rounded button-mini nomargin",
"applyClass": "button-color",
"cancelClass": "button-light",
ranges: {
'Today': [moment(), moment()],
'Yesterday': [moment().subtract(1, 'days'), moment().subtract(1, 'days')],
'Last 7 Days': [moment().subtract(6, 'days'), moment()],
'Last 30 Days': [moment().subtract(29, 'days'), moment()],
'This Month': [moment().startOf('month'), moment().endOf('month')],
'Last Month': [moment().subtract(1, 'month').startOf('month'), moment().subtract(1, 'month').endOf('month')]
}
}, cb);
// .daterange4
$(".daterange4").daterangepicker({
autoUpdateInput: false,
locale: {
cancelLabel: 'Clear'
},
"buttonClasses": "button button-rounded button-mini nomargin",
"applyClass": "button-color",
"cancelClass": "button-light"
});
$(".daterange4").on('apply.daterangepicker', function(ev, picker) {
$(this).val(picker.startDate.format('MM/DD/YYYY') + ' - ' + picker.endDate.format('MM/DD/YYYY'));
});
$(".daterange4").on('cancel.daterangepicker', function(ev, picker) {
$(this).val('');
});
});
</script>
<!-- Bootstrap File Upload Plugin -->
<script type="text/javascript" src="js/components/bs-filestyle.js"></script>
<script type="text/javascript">
$(document).on('ready', function() {
$("#input-11").fileinput({
maxFileCount: 10,
allowedFileTypes: ["image", "video"]
});
$("#input-12").fileinput({
showPreview: false,
showCaption: true,
allowedFileExtensions: ["jpg", "csv", "pdf", "doc", "docx"],
elErrorContainer: "#errorBlock"
});
});
</script>
</body>
</html>
OHA YOOOO