<extend name="Public/base"/>
<block name="body"> 
<script src="__JS__/layer/layer.js" type="text/javascript"></script>
<script src="__JS__/xiaobing.js" type="text/javascript"></script>       
            <div class="page_order">
                <div class="panel-heading">
                    <p><strong>井手齿科クリニック（成都店）</strong></p>
                     <p class="text-red">本页为初诊顾客专用预约表，复诊的顾客请直接电话联系我们。</p>
                </div>
                <div class="panel-body">
                    <!-- form -->
                    <div class="form-panel">
                       <form class="form-horizontal ajax-post"  id="formlist" action="{:U('Messages/add')}" method="post">
                        <div class="row">

                          <div class="form-group clearfix">
                            <div class="col-xs-3">
                                <label for="#" class="fl">姓名</label>
                                <span class="need fr">必填</span>
                            </div>
                            <div class="col-xs-9">
                                 <input type="text" class="form-control" id="exampleInputName" placeholder="请输入您的姓名" name="name" data-validate="required:姓名不能为空">
                            </div>
                          </div>
                          <div class="form-group clearfix">
                            <div class="col-xs-3">
                                <label for="#" class="fl">电话</label>
                                <span class="need fr">必填</span>
                            </div>
                            <div class="col-xs-9">
                                 <input type="text" class="form-control" id="exampleInputPhone" placeholder="请输入您的电话号码" name="phone" data-validate="required:电话不能为空,tel:电话格式错误">
                            </div>
                          </div>
                          <div class="form-group clearfix">
                            <div class="col-xs-3" style="padding:60px 20px">
                                <label for="#" class="fl">留言咨询</label>
                                <span class="need fr">必填</span>
                            </div>
                            <div class="col-xs-9">
                                 <textarea class="form-control text" placeholder="您可以在这里输入您的问题" name="content" data-validate="required:留言内容不能为空"></textarea>
                            </div>
                          </div>
                          <div class="form-group clearfix">
                            <div class="col-xs-3">
                                <label for="#" class="fl">验证码</label>
                                <span class="need fr">必填</span>
                            </div>
                            <div class="col-xs-9">
                                <input type="text" name="verify" class="form-control vcode" id="exampleInputAddress3" placeholder="请输入右侧验证码">
                                <img src="{:U('Messages/verify')}" width="186" height="50" class="margin-left-20" id="de" onclick="reloadcode()">
                            </div>
                          </div>


                        </div>

                        <div class="col-xs-12" style="text-align:center;margin-top:20px">
                              <button type="submit" id="submitTiJiao" class="btn btn-submit" >立即在线预约</button>
                        </div>
                       </form>
                    </div>

                </div>
                <div class="panel-foot">
                    <p>您也可以选择直接与我们取得联系，请拨打以下电话</p>
                    <p style="font-size:24px;color:#f4901e"><b>{:C("COM_TEL.0")}</b></p>
                </div>
                
            </div>
<script>
$(function(){
$('#submit').xbValidform();
});
</script>
<script type="text/javascript">
function reloadcode(){
var verify=document.getElementById('de');
verify.setAttribute('src','{:U('Messages/verify')}?'+Math.random());
}
</script>          
</block>          