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

<h2>Prescriber Request Form</h2>
<p>
Use this form to submit a request or communication to our pharmacy.
Please complete all required fields so we can process your request promptly.
</p>
<p class=”required-note”>* Required information</p>

<!– Prescriber Information –>
<div class=”row”>
<input type=”text” name=”prescriber_name” placeholder=”Prescriber Full Name *” required>
<input type=”text” name=”practice_name” placeholder=”Practice / Clinic Name *” required>
</div>

<div class=”row”>
<input type=”tel” name=”prescriber_phone” placeholder=”Phone Number *” required>
<input type=”email” name=”prescriber_email” placeholder=”Email Address *” required>
</div>

<div class=”row”>
<input type=”text” name=”fax” placeholder=”Fax Number”>
<input type=”text” name=”npi” placeholder=”NPI Number”>
</div>

<!– Patient Information –>
<h3>Patient Information</h3>

<div class=”row”>
<input type=”text” name=”patient_first_name” placeholder=”Patient First Name *” required>
<input type=”text” name=”patient_last_name” placeholder=”Patient Last Name *” required>
</div>

<div class=”row”>
<input type=”date” name=”patient_dob” placeholder=”Patient Date of Birth”>
<input type=”tel” name=”patient_phone” placeholder=”Patient Phone Number”>
</div>

<!– Request Details –>
<div class=”row”>
<select name=”request_type” required>
<option value=””>Request Type *</option>
<option>New Prescription</option>
<option>Prescription Refill Authorization</option>
<option>Medication Change</option>
<option>Prior Authorization</option>
<option>Clinical Question</option>
<option>Other</option>
</select>

<input type=”text” name=”medication_name” placeholder=”Medication Name”>
</div>

<label>Request Details / Instructions</label>
<textarea
name=”request_details”
placeholder=”Please provide any instructions or relevant details”
required
></textarea>

<!– Consent –>
<label class=”checkbox”>
<input type=”checkbox” required>
I confirm that the information provided is accurate and authorized.
</label>

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

</form>

<style>
.prescriber-request-form {
max-width: 900px;
margin: auto;
font-family: Arial, sans-serif;
}

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

.prescriber-request-form h3 {
margin-top: 30px;
}

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

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

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

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

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

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

.prescriber-request-form button {
background: #28a745;
color: #