File: /home/imensosw/www/imenso.co/dev/prc/index.html
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<title>Patient Portal</title>
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<body>
<section class="banner5">
<div class="container">
<div class="row">
<div class="col-md-12">
<div role="document" class="modal-dialog login-modal">
<div class="modal-content">
<div class="modal-body">
<div class="container-fluid">
<div class="row">
<div class="col-md-5 mb-5">
<img class="ml-5 mb-3" src="images/client-logo-2.png" width="150">
</div>
<div class="col-md-7 text-right d-none d-md-block">
<p class="mr-5">To make a payment by phone, please dial <a href="tel:1-855-829-0149" data-toggle="tooltip" title="Please note: This is an automated service only."> 1-855-829-0149</a><small> <br /> (Payment Code required)</small></p>
</div>
</div>
<div class="row d-flex align-items-center">
<div class="col-md-6 border-right form-2">
<div class="slogan-2 px-5">
<section class="light">
<h1>Welcome to our enhanced Patient Portal</h1>
<p>Our Patient Portal is an easy, secure way for you to better understand your medical bill and the portion you owe.</p>
</section>
<ul class="bullets">
<li><i class="fa fa-check"></i> Login with your e-mail address</li>
<li><i class="fa fa-check"></i> Sign-up for e-Statements</li>
<li><i class="fa fa-check"></i> Link Multiple Payment Codes</li>
<li><i class="fa fa-check"></i> View Account Details</li>
</ul>
<a class="btn register btn-secondary mt-3" href="javascript:;">Register Now</a>
</div>
<form class="px-5" id="form-2" style="display: none;">
<div class="form-group">
<label for="">Payment Code from recent Statement:<a href="javascript:;" data-toggle="modal" data-target="#paymentCode"> (What's this?)</a></label>
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="Payment Code e.g. 14##########">
</div>
<div class="form-group">
<label for="">Last Name as it appears on Statement:</label>
<input type="text" class="form-control" id="" placeholder="Last Name as it appears on Statement">
</div>
<div class="form-group">
<label for="">E-mail Address</label>
<input type="email" class="form-control" id="" aria-describedby="emailHelp" placeholder="Enter your e-mail">
</div>
<div class="form-group">
<label for="">Date of Birth (Optional)</label>
<input type="text" class="form-control" id="" placeholder="Date of Birth">
</div>
<div class="mt-5 d-flex justify-content-between">
<button type="button" class="btn btn-login">Submit</button>
</div>
</form>
</div>
<div class="col-md-6">
<div class="px-5">
<div class="reg-ben">
<form class="" id="form-1">
<div class="pay-bill-fields">
<div class="form-group">
<label for="">Payment Code from recent Statement:<a href="javascript:;" data-toggle="modal" data-target="#paymentCode"> (What's this?)</a></label>
<input type="text" class="form-control" id="" aria-describedby="emailHelp" placeholder="e.g. 14##########">
</div>
<div class="form-group">
<label for="">Last Name as it appears on Statement:</label>
<input type="text" class="form-control" id="" placeholder="e.g. Lee">
</div>
<button type="button" class="btn btn-login mt-3">Pay Bill</button>
</div>
<div class="login-fields" style="display: none;">
<div class="form-group">
<label for="">E-mail Address</label>
<input type="email" class="form-control" id="" aria-describedby="emailHelp" placeholder="Enter your e-mail">
</div>
<div class="form-group">
<label for="">Password</label>
<input type="text" class="form-control" id="" placeholder="Enter your password">
</div>
<a href="dashboard.html" class="mt-3 btn btn-login">Login</a>
</div>
<div class="mt-5">
<p class="d-pay-bill" style="display: none;"><span>Don't want to login?</span> <a href="javascript:;" class="btn btn-secondary ml-2"> Pay bill directly</a></p>
<p class="login-first"><span>Have an account?</span><a href="javascript:;" class="btn btn-secondary ml-2"> Login</a></p>
</div>
</form>
</div>
<div class="reg-cta" style="display: none;">
<a href="" class="btn-block btn btn-login">Pay Bill</a>
<a href="" class="btn-block btn mt-4 btn-secondary">Login</a>
</div>
</div>
</div>
<div class="col-md-12 d-block d-md-none">
<hr />
<section class="light">
<h1 class="text-center">New User? Register</h1>
<p>We're excited to offer you NEW tools to get the answers you need to better understand your medical bill and the portion you owe.</p>
<ul class="bullets">
<li><i class="fa fa-check"></i> Login with your e-mail address</li>
<li><i class="fa fa-check"></i> Sign-up for e-Statements</li>
<li><i class="fa fa-check"></i> Link Multiple Payment Codes</li>
<li><i class="fa fa-check"></i> View Account Details</li>
</ul>
</section>
<div class="slogan-2 px-5">
<a class="btn register btn-secondary mt-3" href="javascript:;">Register Now</a>
</div>
<p class="text-center highlight">To make a payment by phone, please dial <a href="tel:1-855-829-0149" data-toggle="tooltip" title="Please note: This is an automated service only."> 1-855-829-0149</a><small> <br /> (Payment Code required)</small></p>
</div>
</div>
</div>
</div> <!--/modal-body-->
<div class="modal-footer text-left">
<div class="ml-5">
<div class="row d-flex align-items-center">
<div class="col-lg-8 col-md-7">
<p>Need help? Please <a href="">chat with us </a> or view some <a href="common-questions.html">commonly asked questions</a></p>
</div>
<div class="col-lg-4 col-md-5 text-right">
<ul class="header-icon mr-5 pl-0">
<li class="blue-bg"><a href="" tooltip="Chat"><img src="images/support.png"/></a></li>
<li class="green-bg"><a href="" tooltip="Commonly Asked Questions"><img src="images/question.png"/></a></li>
<li class="gray-bg"><a href="" tooltip="E-mail Us"><img src="images/envelope.png"/></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<div class="modal fade" id="paymentCode" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Payment Code</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<img src="images/code.png" class="img-fluid">
</div>
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</div>
<nav class="fab" style="display: none;">
<a href="#" class="buttons" tooltip="E-mail Us"></a>
<a href="#" class="buttons" tooltip="Commonly Asked Questions"></a>
<a class="buttons" tooltip="Chat Now" href="#"></a>
</nav>
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