<?php require_once ('php/connect.php'); ?>
<?php include ('php/display.php'); ?>
<?php
date_default_timezone_set("America/Chicago");
$todaydate = date("Y-m-d");
$IP = $_SERVER['REMOTE_ADDR'];
?>
<!DOCTYPE html>
<html lang="en">
<head>
<title>T.I.P.S. Program - Successful Medical Billing</title>
<meta charset="utf-8">
<meta name="format-detection" content="telephone=no"/>
<link rel="icon" href="images/favicon.ico" type="image/x-icon">
<link rel="stylesheet" href="css/grid.css">
<link rel="stylesheet" href="css/style.css">
<link rel="stylesheet" href="css/search.css">
<link rel="stylesheet" href="css/camera.css">
<link rel="stylesheet" href="css/tips-contactform.css">
<link rel="stylesheet" href="css/jquery.fancybox.css">
<link rel="stylesheet" href="//code.jquery.com/ui/1.11.4/themes/smoothness/jquery-ui.css">
<script src="js/jquery-1.8.1.min.js"></script>
<script src="js/jquery.js"></script>
<script src="js/jquery-migrate-1.2.1.js"></script>
<!--[if lt IE 9]>
<html class="lt-ie9">
<div style=' clear: both; text-align:center; position: relative;'>
<a href="http://windows.microsoft.com/en-US/internet-explorer/..">
<img src="images/ie8-panel/warning_bar_0000_us.jpg" border="0" height="42" width="820"
alt="You are using an outdated browser. For a faster, safer browsing experience, upgrade for free today."/>
</a>
</div>
<script src="js/html5shiv.js"></script>
<![endif]-->
<script src='js/device.min.js'></script>
<script type="text/javascript">
function MM_swapImgRestore() { //v3.0
var i,x,a=document.MM_sr; for(i=0;a&&i<a.length&&(x=a[i])&&x.oSrc;i++) x.src=x.oSrc;
}
function MM_preloadImages() { //v3.0
var d=document; if(d.images){ if(!d.MM_p) d.MM_p=new Array();
var i,j=d.MM_p.length,a=MM_preloadImages.arguments; for(i=0; i<a.length; i++)
if (a[i].indexOf("#")!=0){ d.MM_p[j]=new Image; d.MM_p[j++].src=a[i];}}
}
function MM_findObj(n, d) { //v4.01
var p,i,x; if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
if(!x && d.getElementById) x=d.getElementById(n); return x;
}
function MM_swapImage() { //v3.0
var i,j=0,x,a=MM_swapImage.arguments; document.MM_sr=new Array; for(i=0;i<(a.length-2);i+=3)
if ((x=MM_findObj(a[i]))!=null){document.MM_sr[j++]=x; if(!x.oSrc) x.oSrc=x.src; x.src=a[i+2];}
}
</script>
</head>
<body onLoad="MM_preloadImages('images/register-over.png')">
<div class="page">
<!--========================================================
HEADER
=========================================================-->
<header>
<div id="stuck_container" class="stuck_container">
<div class="container">
<div class="row">
<div class="grid_14">
<div class="brand">
<a href="index.php"><img src="images/SMB_logo2.png" alt="" width="150" height="150"/></a>
</div>
</div>
<div class="grid_13">
<ul class="list01">
<li><a class="no-border" href="cart.php">MY CART</a></li>
<li><a href="register.php">REGISTER</a></li>
<li><a href="refresher.php">REFRESHER COURSES</a></li>
<li><a class="no-margin" href="https://successfulmedicalbilling.com/login/" target="_blank">ATTENDEE PORTAL</a></li>
</ul>
</div>
</div>
<nav class="nav">
<ul class="sf-menu">
<li class="active"> <a href="./">Home</a> </li>
<li> <a href="about-successful-medical-billing.php">About</a>
<ul>
<li>
<a href="about-successful-medical-billing.php">Meet Dr. Farrugia</a>
</li>
<li>
<a href="SMB-courses.php"> Live Courses</a>
</li>
<li>
<a href="https://www.smbdu.com" target="blank"> Online Courses</a>
</li></ul></li>
<li> <a href="speaking-schedule.php">Schedule</a> </li>
<li> <a href="book.php">Books</a></li>
<li> <a href="claims-support.php">Additional Services</a>
<ul>
<li><a href="claims-support.php">Claiming Wheels</a></li>
<li><a href="tips-program.php">T.I.P.S. Program</a></li>
</ul></li>
<li> <a href="host-a-course.php">Host</a> </li>
<li> <a href="contact.php">Contact</a></li>
</ul>
</nav>
</div>
</div>
</header>
<!--========================================================
CONTENT
=========================================================-->
<main>
<section>
<div class="well-02">
<div class="container">
<div class="row">
<div class="grid_12">
<h1 class="wow fadeInRight"><?php echo $TIPS_Hdr; ?></h1>
<?php echo $TIPS_Content; ?>
</div>
</div>
</div>
</div>
</section>
<section>
<div class="well-04 __mod2">
<div class="container">
<h5 class=" wow fadeInRight">Request Information</h5>
<form action="php/tips-form.php" method="post" class="tips-form" id="tips-form">
<div class="row">
<div class="grid_6">
<label class="message">
<textarea name="message" placeholder="<?php echo $TIPSplaceholder_Message; ?>" required></textarea>
</label>
</div>
<div class="grid_6">
<label class="name">
<input type="text" name="name" placeholder="<?php echo $TIPSplaceholder_Name; ?>" value="" required/>
</label>
<label class="phone">
<input type="text" name="phone" placeholder="<?php echo $TIPSplaceholder_Phone; ?>" value="" required/>
</label>
<label class="email">
<input type="text" name="email" placeholder="<?php echo $TIPSplaceholder_Email; ?>" value="" required/>
</label>
<input type="submit" class="submit-btn" value="Submit Request">
<input name="TIPS" type="hidden" id="TIPS" value="Yes">
<input name="date" type="hidden" id="date" value="<?php echo $todaydate; ?>">
<input name="IP_Address" type="hidden" id="IP_Address" value="<?php echo $IP; ?>">
</div>
</div>
</form>
</div>
</div>
</section>
</main>
<!--========================================================
FOOTER
=========================================================-->
<footer>
<div class="bg-wrap">
<div class="footer-well">
<div class="container">
<div class="row">
<div class="grid_4">
<div class="copyright">
<h6>Copyright</h6>
<p>© Chris P. Farrugia</p>
<p><a href="#">Privacy policy</a></p>
<p>Website By:</span>
<a href="http://www.savvysitedesigns.com" target="_blank">Savvy Site Designs</a></p>
</div>
</div>
<div class="grid_4">
<div class="copyright">
<h6>QUICK LINKS</h6>
<p><span><a href="about-successful-medical-billing.php">About</a></span></p>
<p><span><a href="SMB-courses.php">Courses</a></span></p>
<p><span><a href="speaking-schedule.php">Schedule</a></span></p>
<p><span><a href="book.php">Books</a></span></p>
<p><span><a href="register.php">Register</a></span></p>
<p><span><a href="host-a-course.php">Host A Course</a></span></p>
<p><span><a href="claims-support.php">Additional Services</a></span></p>
<p><span><a href="https://successfulmedicalbilling.com/login/" target="_blank">Attendee Portal</a></span></p>
<p><span><a href="refresher.php">Refresher Courses</a></span></p>
<p><span><a href="cart.php">My Cart</a></span></p>
</div>
</div>
<div class="grid_4">
<div class="copyright">
<h6>CONTACT US</h6>
<p><span>Email: <a href="mailto:info@successfulmedicalbilling.com">info@successfulmedicalbilling.com</a></span></p>
<p><span>Phone: 850.261.5613</span></p>
</div>
</div>
</div>
</div>
</div>
</div>
</footer>
</div>
<script src="//ajax.googleapis.com/ajax/libs/jquery/1.10.2/jquery.min.js"></script>
<script src="//cdnjs.cloudflare.com/ajax/libs/jquery-form-validator/2.2.1/jquery.form-validator.min.js"></script>
<script>
$.validate({
form : '#FormSupport',
validateOnBlur : false, // disable validation when input looses focus
errorMessagePosition : 'top',// Instead of 'element' which is default
scrollToTopOnError : false // Set this property to true if you have a long form
});
</script>
<script src="//code.jquery.com/jquery-1.10.2.js"></script>
<script src="//code.jquery.com/ui/1.11.4/jquery-ui.js"></script>
<script>
$(function() {
$( "#datepicker" ).datepicker();
});
</script>
<?php echo $alert; ?>
<script src="js/script.js"></script>
</body>
</html> |