<?php
$this->load->view('top');
$adminRes = get_site_email();
?>
<section class="banner_category" style="background-image: url('<?= theme_url(); ?>img/contact.jpg');">
    <div class="container">
        <h1 class="banner_subtitle">Top Best Sexologist</h1>
        <h2 class="banner_title">Contact</h2>
    </div>
</section>
<div class="page_breadcrumbs">
    <div class="container">
        <ul>
            <li><a href="<?=base_url()?>">Home</a></li>
            <li>Contact Us</li>
        </ul>
    </div>
</div>
<div class="contact_area bg-grey">
    <div class="container">
        <div class="row">
            <div class="col-lg-8">
                <div class="contact-message">
                    <div class="section-title style-2">
                        <h3>CONTACT US</h3>
                    </div>
                    <p id="status_res"></p>
                    <form id="contact-form" method="post" class="contact-form">
                        <div class="row">
                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <input class="form_input" name="first_name" id="first_name" placeholder="Name *" pattern="[a-z A-Z]+" type="text" required="">
                                    </label>
                                </div>
                            </div>
                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <input class="form_input" name="phone" id="phone" type="tel" placeholder="Mobile Number *" maxlength="13" minlength="8" onKeyPress="return isNumberKey(event)" required="">
                                    </label>
                                </div>
                            </div>

                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <input class="form_input" name="email" id="email" type="email" placeholder="Email ID *" required="">

                                    </label>
                                </div>
                            </div>

                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <input class="form_input" name="city" id="city" placeholder="Enter City *" type="text" required="">
                                    </label>
                                </div>
                            </div>

                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <select class="form_input" name="country" id="country" required="">
                                            <option value="">Select Country</option>
                                            <option value="Afghanistan">Afghanistan</option>
                                            <option value="Albania">Albania</option>
                                            <option value="Algeria">Algeria</option>
                                            <option value="American Samoa">American Samoa</option>
                                            <option value="Andorra">Andorra</option>
                                            <option value="Angola">Angola</option>
                                            <option value="Anguilla">Anguilla</option>
                                            <option value="Antartica">Antarctica</option>
                                            <option value="Antigua and Barbuda">Antigua and Barbuda</option>
                                            <option value="Argentina">Argentina</option>
                                            <option value="Armenia">Armenia</option>
                                            <option value="Aruba">Aruba</option>
                                            <option value="Australia">Australia</option>
                                            <option value="Austria">Austria</option>
                                            <option value="Azerbaijan">Azerbaijan</option>
                                            <option value="Bahamas">Bahamas</option>
                                            <option value="Bahrain">Bahrain</option>
                                            <option value="Bangladesh">Bangladesh</option>
                                            <option value="Barbados">Barbados</option>
                                            <option value="Belarus">Belarus</option>
                                            <option value="Belgium">Belgium</option>
                                            <option value="Belize">Belize</option>
                                            <option value="Benin">Benin</option>
                                            <option value="Bermuda">Bermuda</option>
                                            <option value="Bhutan">Bhutan</option>
                                            <option value="Bolivia">Bolivia</option>
                                            <option value="Bosnia and Herzegowina">Bosnia and Herzegowina</option>
                                            <option value="Botswana">Botswana</option>
                                            <option value="Bouvet Island">Bouvet Island</option>
                                            <option value="Brazil">Brazil</option>
                                            <option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
                                            <option value="Brunei Darussalam">Brunei Darussalam</option>
                                            <option value="Bulgaria">Bulgaria</option>
                                            <option value="Burkina Faso">Burkina Faso</option>
                                            <option value="Burundi">Burundi</option>
                                            <option value="Cambodia">Cambodia</option>
                                            <option value="Cameroon">Cameroon</option>
                                            <option value="Canada">Canada</option>
                                            <option value="Cape Verde">Cape Verde</option>
                                            <option value="Cayman Islands">Cayman Islands</option>
                                            <option value="Central African Republic">Central African Republic</option>
                                            <option value="Chad">Chad</option>
                                            <option value="Chile">Chile</option>
                                            <option value="China">China</option>
                                            <option value="Christmas Island">Christmas Island</option>
                                            <option value="Cocos Islands">Cocos (Keeling) Islands</option>
                                            <option value="Colombia">Colombia</option>
                                            <option value="Comoros">Comoros</option>
                                            <option value="Congo">Congo</option>
                                            <option value="Congo">Congo, the Democratic Republic of the</option>
                                            <option value="Cook Islands">Cook Islands</option>
                                            <option value="Costa Rica">Costa Rica</option>
                                            <option value="Cota D'Ivoire">Cote d'Ivoire</option>
                                            <option value="Croatia">Croatia (Hrvatska)</option>
                                            <option value="Cuba">Cuba</option>
                                            <option value="Cyprus">Cyprus</option>
                                            <option value="Czech Republic">Czech Republic</option>
                                            <option value="Denmark">Denmark</option>
                                            <option value="Djibouti">Djibouti</option>
                                            <option value="Dominica">Dominica</option>
                                            <option value="Dominican Republic">Dominican Republic</option>
                                            <option value="East Timor">East Timor</option>
                                            <option value="Ecuador">Ecuador</option>
                                            <option value="Egypt">Egypt</option>
                                            <option value="El Salvador">El Salvador</option>
                                            <option value="Equatorial Guinea">Equatorial Guinea</option>
                                            <option value="Eritrea">Eritrea</option>
                                            <option value="Estonia">Estonia</option>
                                            <option value="Ethiopia">Ethiopia</option>
                                            <option value="Falkland Islands">Falkland Islands (Malvinas)</option>
                                            <option value="Faroe Islands">Faroe Islands</option>
                                            <option value="Fiji">Fiji</option>
                                            <option value="Finland">Finland</option>
                                            <option value="France">France</option>
                                            <option value="France Metropolitan">France, Metropolitan</option>
                                            <option value="French Guiana">French Guiana</option>
                                            <option value="French Polynesia">French Polynesia</option>
                                            <option value="French Southern Territories">French Southern Territories</option>
                                            <option value="Gabon">Gabon</option>
                                            <option value="Gambia">Gambia</option>
                                            <option value="Georgia">Georgia</option>
                                            <option value="Germany">Germany</option>
                                            <option value="Ghana">Ghana</option>
                                            <option value="Gibraltar">Gibraltar</option>
                                            <option value="Greece">Greece</option>
                                            <option value="Greenland">Greenland</option>
                                            <option value="Grenada">Grenada</option>
                                            <option value="Guadeloupe">Guadeloupe</option>
                                            <option value="Guam">Guam</option>
                                            <option value="Guatemala">Guatemala</option>
                                            <option value="Guinea">Guinea</option>
                                            <option value="Guinea-Bissau">Guinea-Bissau</option>
                                            <option value="Guyana">Guyana</option>
                                            <option value="Haiti">Haiti</option>
                                            <option value="Heard and McDonald Islands">Heard and Mc Donald Islands</option>
                                            <option value="Holy See">Holy See (Vatican City State)</option>
                                            <option value="Honduras">Honduras</option>
                                            <option value="Hong Kong">Hong Kong</option>
                                            <option value="Hungary">Hungary</option>
                                            <option value="Iceland">Iceland</option>
                                            <option value="India" selected>India</option>
                                            <option value="Indonesia">Indonesia</option>
                                            <option value="Iran">Iran (Islamic Republic of)</option>
                                            <option value="Iraq">Iraq</option>
                                            <option value="Ireland">Ireland</option>
                                            <option value="Israel">Israel</option>
                                            <option value="Italy">Italy</option>
                                            <option value="Jamaica">Jamaica</option>
                                            <option value="Japan">Japan</option>
                                            <option value="Jordan">Jordan</option>
                                            <option value="Kazakhstan">Kazakhstan</option>
                                            <option value="Kenya">Kenya</option>
                                            <option value="Kiribati">Kiribati</option>
                                            <option value="Democratic People's Republic of Korea">Korea, Democratic People's Republic of</option>
                                            <option value="Korea">Korea, Republic of</option>
                                            <option value="Kuwait">Kuwait</option>
                                            <option value="Kyrgyzstan">Kyrgyzstan</option>
                                            <option value="Lao">Lao People's Democratic Republic</option>
                                            <option value="Latvia">Latvia</option>
                                            <option value="Lebanon">Lebanon</option>
                                            <option value="Lesotho">Lesotho</option>
                                            <option value="Liberia">Liberia</option>
                                            <option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
                                            <option value="Liechtenstein">Liechtenstein</option>
                                            <option value="Lithuania">Lithuania</option>
                                            <option value="Luxembourg">Luxembourg</option>
                                            <option value="Macau">Macau</option>
                                            <option value="Macedonia">Macedonia, The Former Yugoslav Republic of</option>
                                            <option value="Madagascar">Madagascar</option>
                                            <option value="Malawi">Malawi</option>
                                            <option value="Malaysia">Malaysia</option>
                                            <option value="Maldives">Maldives</option>
                                            <option value="Mali">Mali</option>
                                            <option value="Malta">Malta</option>
                                            <option value="Marshall Islands">Marshall Islands</option>
                                            <option value="Martinique">Martinique</option>
                                            <option value="Mauritania">Mauritania</option>
                                            <option value="Mauritius">Mauritius</option>
                                            <option value="Mayotte">Mayotte</option>
                                            <option value="Mexico">Mexico</option>
                                            <option value="Micronesia">Micronesia, Federated States of</option>
                                            <option value="Moldova">Moldova, Republic of</option>
                                            <option value="Monaco">Monaco</option>
                                            <option value="Mongolia">Mongolia</option>
                                            <option value="Montserrat">Montserrat</option>
                                            <option value="Morocco">Morocco</option>
                                            <option value="Mozambique">Mozambique</option>
                                            <option value="Myanmar">Myanmar</option>
                                            <option value="Namibia">Namibia</option>
                                            <option value="Nauru">Nauru</option>
                                            <option value="Nepal">Nepal</option>
                                            <option value="Netherlands">Netherlands</option>
                                            <option value="Netherlands Antilles">Netherlands Antilles</option>
                                            <option value="New Caledonia">New Caledonia</option>
                                            <option value="New Zealand">New Zealand</option>
                                            <option value="Nicaragua">Nicaragua</option>
                                            <option value="Niger">Niger</option>
                                            <option value="Nigeria">Nigeria</option>
                                            <option value="Niue">Niue</option>
                                            <option value="Norfolk Island">Norfolk Island</option>
                                            <option value="Northern Mariana Islands">Northern Mariana Islands</option>
                                            <option value="Norway">Norway</option>
                                            <option value="Oman">Oman</option>
                                            <option value="Pakistan">Pakistan</option>
                                            <option value="Palau">Palau</option>
                                            <option value="Panama">Panama</option>
                                            <option value="Papua New Guinea">Papua New Guinea</option>
                                            <option value="Paraguay">Paraguay</option>
                                            <option value="Peru">Peru</option>
                                            <option value="Philippines">Philippines</option>
                                            <option value="Pitcairn">Pitcairn</option>
                                            <option value="Poland">Poland</option>
                                            <option value="Portugal">Portugal</option>
                                            <option value="Puerto Rico">Puerto Rico</option>
                                            <option value="Qatar">Qatar</option>
                                            <option value="Reunion">Reunion</option>
                                            <option value="Romania">Romania</option>
                                            <option value="Russia">Russian Federation</option>
                                            <option value="Rwanda">Rwanda</option>
                                            <option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
                                            <option value="Saint LUCIA">Saint LUCIA</option>
                                            <option value="Saint Vincent">Saint Vincent and the Grenadines</option>
                                            <option value="Samoa">Samoa</option>
                                            <option value="San Marino">San Marino</option>
                                            <option value="Sao Tome and Principe">Sao Tome and Principe</option>
                                            <option value="Saudi Arabia">Saudi Arabia</option>
                                            <option value="Senegal">Senegal</option>
                                            <option value="Seychelles">Seychelles</option>
                                            <option value="Sierra">Sierra Leone</option>
                                            <option value="Singapore">Singapore</option>
                                            <option value="Slovakia">Slovakia (Slovak Republic)</option>
                                            <option value="Slovenia">Slovenia</option>
                                            <option value="Solomon Islands">Solomon Islands</option>
                                            <option value="Somalia">Somalia</option>
                                            <option value="South Africa">South Africa</option>
                                            <option value="South Georgia">South Georgia and the South Sandwich Islands</option>
                                            <option value="Span">Spain</option>
                                            <option value="SriLanka">Sri Lanka</option>
                                            <option value="St. Helena">St. Helena</option>
                                            <option value="St. Pierre and Miguelon">St. Pierre and Miquelon</option>
                                            <option value="Sudan">Sudan</option>
                                            <option value="Suriname">Suriname</option>
                                            <option value="Svalbard">Svalbard and Jan Mayen Islands</option>
                                            <option value="Swaziland">Swaziland</option>
                                            <option value="Sweden">Sweden</option>
                                            <option value="Switzerland">Switzerland</option>
                                            <option value="Syria">Syrian Arab Republic</option>
                                            <option value="Taiwan">Taiwan, Province of China</option>
                                            <option value="Tajikistan">Tajikistan</option>
                                            <option value="Tanzania">Tanzania, United Republic of</option>
                                            <option value="Thailand">Thailand</option>
                                            <option value="Togo">Togo</option>
                                            <option value="Tokelau">Tokelau</option>
                                            <option value="Tonga">Tonga</option>
                                            <option value="Trinidad and Tobago">Trinidad and Tobago</option>
                                            <option value="Tunisia">Tunisia</option>
                                            <option value="Turkey">Turkey</option>
                                            <option value="Turkmenistan">Turkmenistan</option>
                                            <option value="Turks and Caicos">Turks and Caicos Islands</option>
                                            <option value="Tuvalu">Tuvalu</option>
                                            <option value="Uganda">Uganda</option>
                                            <option value="Ukraine">Ukraine</option>
                                            <option value="United Arab Emirates">United Arab Emirates</option>
                                            <option value="United Kingdom">United Kingdom</option>
                                            <option value="United States">United States</option>
                                            <option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
                                            <option value="Uruguay">Uruguay</option>
                                            <option value="Uzbekistan">Uzbekistan</option>
                                            <option value="Vanuatu">Vanuatu</option>
                                            <option value="Venezuela">Venezuela</option>
                                            <option value="Vietnam">Viet Nam</option>
                                            <option value="Virgin Islands (British)">Virgin Islands (British)</option>
                                            <option value="Virgin Islands (U.S)">Virgin Islands (U.S.)</option>
                                            <option value="Wallis and Futana Islands">Wallis and Futuna Islands</option>
                                            <option value="Western Sahara">Western Sahara</option>
                                            <option value="Yemen">Yemen</option>
                                            <option value="Serbia">Serbia</option>
                                            <option value="Zambia">Zambia</option>
                                            <option value="Zimbabwe">Zimbabwe</option>
                                        </select>

                                    </label>
                                </div>
                            </div>

                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <input class="form_input" type="text" name="state" id="state" placeholder="Enter State *" value="" required="">

                                    </label>
                                </div>
                            </div>

                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group">
                                    <label class="input_label">
                                        <input class="form_input" type="number" placeholder="Enter Your Age *" name="age" id="age" required>
                                    </label>
                                </div>
                            </div>
                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group radioForm">
                                    <label class="radio_btn"><input name="gender" type="radio" value="Male" checked=""> Male</label>
                                    <label class="radio_btn"><input name="gender" type="radio" value="Female">Female</label>
                                </div>
                            </div>
                            <div class="col-lg-6 col-md-6 col-sm-6">
                                <div class="form-group radioForm">
                                    <label class="radio_btn"><input name="marital" type="radio" value="Married" checked=""> Married</label>
                                    <label class="radio_btn"><input name="marital" type="radio" value="Unmarried">Unmarried</label>
                                </div>
                            </div>

                          


                            <div class="col-lg-12 col-md-12">
                                <div class="form-group">
                                    <label class="input_label">
                                        <textarea name="message" id="message" required="" class="form_input" placeholder="Problems *"></textarea>
                                    </label>
                                </div>
                            </div>
                            
                             <div class="col-lg-12 col-md-12">
                                <div class="form-group">
                                   
                                    
                                    <input type="hidden" name="action" value="postData" />
                            <div class="check_with_text">
        <input name="tRap" id="tRap" type="checkbox"> <span>If you are a <span class="human">HUMAN</span> please leave it blank.**</span>
        </div>
                                </div>
                            </div>

                            <div class="contact-btn">
                                <button class="contact_btn hover_btn" id="contact_sub" name="contact_sub" type="submit">Submit</button>
                            </div>

                        </div>
                    </form>
                </div>
            </div>
            <div class="col-lg-4">
                <div class="contact-info-three">
                    <div class="single-info">
                        <h4> <?= SITENAME; ?></h4>
                        <div class="text"><?= $adminRes->address; ?></div>
                        <!-- <a class="link-btn" href="tel:<?= $adminRes->phone; ?>"><?= $adminRes->phone; ?></a> <br> -->
                        <!-- <a class="link-btn" href=""><?= $adminRes->admin_email; ?></a>
                        <a class="link-btn" href="">www.dawakhanas.com</a> -->




                    </div>
                    <div class="single-info">
                        <h4>Contact Person:</h4>
                        <div class="wrapper-box">
                            Mr. Kishan Lal Clinic (CEO)
                        </div>
                    </div>
                    <div class="single-info">
                        <h4>All 7 days open</h4>
                        <div class="wrapper-box">
                            Timings <br>
                            12 to 6 Monday to Saturday & 12 to 4 on Sunday
                        </div>
                    </div>
                    <div class="single-info">
                        <img src="<?= theme_url() ?>/images/cod.png" alt="Cash On Delivery" title="Cash On Delivery">
                    </div>
                </div>
            </div>
        </div>
    </div>
</div>

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<?php $this->load->view('bottom'); ?>