record-request.php

<?php include 'header.php'; ?>

<div class="container content">
			<div class="col-md-12">

			<h2><b>Patient Record Request</b></h2>
					<br><br>
					<p>To request
						 <b class="thicker">Fenise Hamilton's
						 </b> record from <b>X</b> please enter the following information.</p>
					<br>


			<form action="" method="POST">
						<div class="row">
						<div class="col-xs-12 col-md-6">
							<div class="form-group">
								<input class="form-control" type="text" name="hw_id" placeholder="Healthwise ID" required>
							</div>
						</div>
						</div>
						<div class="row">
						<div class="col-xs-12 col-md-6">
							<div class="form-group">
								<input type="text" class="form-control" name="full_name" placeholder="Full Name" required>
							</div>
						</div>
						</div>
						<div class="row">
						<div class="col-xs-12 col-md-6">
							<div class="form-group">
								<input type="password" class="form-control" name="password" placeholder="Password" required>
							</div>
						</div>
						</div>
						<div class="row">
							<div class="col-xs-12 col-md-3">
							<div style="margin-bottom: 5px;">
								<button name="submit" class="btn btn-block btn-submit-rq">Request Record</button>
							</div>
							</div>
							<div class="col-xs-12 col-md-3">
								<button class="btn btn-block btn-cancel-rq" onclick="reset();">Cancel</button>
							</div>
							<div class="col-xs-6 col-md-6 hidden-md-down">
							</div>
						</div>
					</form>
			</div>
</div>
<br><br><br><br><br><br>

<?php include 'footer.php'; ?>