<form method=”post” class=”patient-request-form”>

<h2>Patient Request Form</h2>
<p>
Use this form to submit a request to our pharmacy.
Please provide as much information as possible so we can assist you quickly.
</p>
<p class=”required-note”>* Required information</p>

<!– Patient Information –>
<div class=”row”>
<input type=”text” name=”first_name” placeholder=”First Name *” required>
<input type=”text” name=”last_name” placeholder=”Last Name *” required>
</div>

<div class=”row”>
<input type=”date” name=”dob” placeholder=”Date of Birth”>
<input type=”tel” name=”phone” placeholder=”Phone Number *” required>
</div>

<div class=”row”>
<input type=”email” name=”email” placeholder=”Email Address”>
<input type=”text” name=”address” placeholder=”Address”>
</div>

<div class=”row”>
<input type=”text” name=”city” placeholder=”City”>
<input type=”text” name=”state” placeholder=”State”>
</div>

<div class=”row”>
<input type=”text” name=”zip” placeholder=”Zip / Postal Code”>
<select name=”request_type” required>
<option value=””>Request Type *</option>
<option>Prescription Refill</option>
<option>Prescription Transfer</option>
<option>Auto-Refill Enrollment</option>
<option>Prescription Synchronization</option>
<option>Consult a Pharmacist</option>
<option>Insurance / Billing Question</option>
<option>General Inquiry</option>
</select>
</div>

<!– Request Details –>
<label>Request Details</label>
<textarea
name=”request_details”
placeholder=”Please describe your request in detail”
required
></textarea>

<label>Preferred Contact Method</label>
<div class=”radio-group”>
<label><input type=”radio” name=”contact_method” value=”Phone” required> Phone</label>
<label><input type=”radio” name=”contact_method” value=”Email”> Email</label>
<label><input type=”radio” name=”contact_method” value=”Text”> Text</label>
</div>

<!– Consent –>
<label class=”checkbox”>
<input type=”checkbox” required>
I authorize this pharmacy to contact me regarding my request.
</label>

<!– Submit –>
<button type=”submit”>SUBMIT REQUEST</button>

</form>

<style>
.patient-request-form {
max-width: 850px;
margin: auto;
font-family: Arial, sans-serif;
}

.patient-request-form h2 {
color: #f15a24;
}

.required-note {
color: red;
font-size: 13px;
}

.row {
display: flex;
gap: 15px;
margin-bottom: 15px;
}

.row input,
.row select {
flex: 1;
}

.patient-request-form input,
.patient-request-form select,
.patient-request-form textarea {
width: 100%;
padding: 12px;
border-radius: 6px;
border: 1px solid #ccc;
font-size: 14px;
}

.patient-request-form textarea {
min-height: 110px;
margin-bottom: 15px;
}

.radio-group {
margin: 10px 0 15px;
}

.radio-group label {
margin-right: 15px;
}

.checkbox {
display: block;
margin: 20px 0;
}

.patient-request-form button {
background: #28a745;
color: #ffffff;
padding: 12px 35px;
border: none;
border-radius: 4px;
cursor: pointer;
font-size: 14px;
}

@media (max-width: 768px) {
.row {
flex-direction: column;
}
}
</style>