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<div class="modalFormParent" id="modalFormParent">
<div class="modalform right background position-relative">
<button class="modalFormClose">X</button>
<form action="admin/InsertReq2.php" method="post" id="" name="user_form" novalidate="novalidate">
<div class="form-group-1">
<input type="text" name="person_name" class="form-control-1" placeholder="Enter Your Name"
required="">
<!-- <input type="hidden" name="page" value="popup" required="">
<input name="redirect_url" type="hidden" value="#"> -->
<input type="text" name="email" class="form-control-1" placeholder="Enter Your E-mail id"
required="">
</div>
<div class="form-group-1">
<input type="text" name="mobile" class="form-control-1" placeholder="Enter Your mobile no"
maxlength="10" minlength="10" required="">
<select name="doctor_name" class="form-control-1" id="" required="">
<option value="">Select Doctor</option>
<option value="Rajeev">Dr Rajeev Agarwal </option>
<option value="Shweta">Dr Shweta Agarwal </option>
</select>
</div>
<div class=" doctorname ">
<div class="form-group-1">
<select id="" class="form-control-1" name="disease" required="">
<option value="">Select Disease</option>
<option value="Arthritis">Arthritis</option>
<option value="Backache ">Backache</option>
<option value="Gout">Gout</option>
<option value="Osteoporosis">Osteoporosis</option>
<option value="Rheumatoid Arthritis">Rheumatoid Arthritis</option>
<option value="Osteoarthritis">Osteoarthritis</option>
<option value="Ankylosing Spondylitis">Ankylosing Spondylitis</option>
<option value="Psoriatic Prthritis">Psoriatic Prthritis</option>
<option value="Sjogren's syndrome">Sjogren's syndrome</option>
<option value="SLE">SLE</option>
<option value="other">Other</option>
</select>
<select id="" class="form-control-1" name="time_slot" required="">
<option value="Select Slot">Select Slot</option>
<option value="08:30AM - 09:00AM">08:30AM - 09:00AM</option>
<option value="09:00AM - 09:30AM">09:00AM - 09:30AM</option>
<option value="06:00PM - 06:30PM">06:00PM - 06:30PM</option>
<option value="06:30PM - 07:00PM">06:30PM - 07:00PM</option>
<option value="07:00PM - 07:30PM">07:00PM - 07:30PM</option>
<option value="07:30PM - 08:00PM">07:30PM - 08:00PM</option>
<option value="08:00PM - 08:30PM">08:00PM - 08:30PM</option>
<option value="08:30PM - 09:00PM">08:30PM - 09:00PM</option>
</select>
</div>
</div>
<div class="form-group-1">
<input class="form-control-1" type="date" name="date" min="2024-08-16">
<select id="" class="form-control-1" name="doctor_consultation" required="">
<option value="">Select mode of consultation</option>
<option value="online">Online Consultation</option>
<option value="offline">Offline Consultation</option>
</select>
</div>
<div class="text-center">
<div class="form-group-1">
<button class="btn-submit" type="submit" name="contact_submit2"><i class="fa fa-calendar"
aria-hidden="true"></i>BOOK NOW</button>
</div>
</div>
</form>
</div>
</div>