master
candice 2 years ago
parent 827d546759
commit 05b7dc61ff

@ -787,11 +787,7 @@ select.gender_pick {border: 1px solid #d1d1d1;
</div> </div>
</div> </div>
<div id="inquiryBox">
<h2>Your Special Request (optional)</h2>
<p></p>
<textarea id="special_request" name="special_request" style="resize:none;"></textarea>
</div>
<div id="inquiryBox"> <div id="inquiryBox">
<h2>Emergency Contact Information (optional)</h2> <h2>Emergency Contact Information (optional)</h2>
@ -831,12 +827,11 @@ select.gender_pick {border: 1px solid #d1d1d1;
</div> </div>
</div> </div>
</div> </div>
<div id="inquiryBox"> <div id="inquiryBox">
<h2>Your Insurance Information (Optional)</h2> <h2>Your Insurance Information and Other Special Request (optional)</h2>
<textarea id="insurance_information" name="insurance_information" style="resize:none;"></textarea>
<textarea id="special_request" name="special_request" style="resize:none;"></textarea>
</div> </div>
<div class="inquiryBtn"> <div class="inquiryBtn">
<input type="hidden" name="toname" value="<?php echo $userinfo[0]->OPI_FirstName; ?>"> <input type="hidden" name="toname" value="<?php echo $userinfo[0]->OPI_FirstName; ?>">
<input type="hidden" name="tomail" value="<?php echo $userinfo[0]->OPI_Email; ?>"> <input type="hidden" name="tomail" value="<?php echo $userinfo[0]->OPI_Email; ?>">

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