<!DOCTYPE html>
<html>
<head>
<title>Pharmacy Complaint Form</title>
<link href="https://fonts.googleapis.com/css?family=Roboto:300,400,500,700" rel="stylesheet">
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.5.0/css/all.css" integrity="sha384-B4dIYHKNBt8Bc12p+WXckhzcICo0wtJAoU8YZTY5qE0Id1GSseTk6S+L3BlXeVIU" crossorigin="anonymous">
<style>
html, body {
min-height: 100%;
}
body, div, form, input, select, p {
padding: 0;
margin: 0;
outline: none;
font-family: Roboto, Arial, sans-serif;
font-size: 14px;
color: #666;
line-height: 22px;
}
h1 {
margin: 15px 0;
font-weight: 400;
}
.testbox {
display: flex;
justify-content: center;
align-items: center;
height: inherit;
padding: 3px;
}
form {
width: 100%;
padding: 20px;
background: #fff;
box-shadow: 0 2px 5px #ccc;
}
input, select, textarea {
margin-bottom: 10px;
border: 1px solid #ccc;
border-radius: 3px;
}
input {
width: calc(100% - 10px);
padding: 5px;
}
select {
width: 100%;
padding: 7px 0;
background: transparent;
}
textarea {
width: calc(100% - 6px);
}
.item {
position: relative;
margin: 10px 0;
}
.item:hover p, .item:hover i {
color: #095484;
}
input:hover, select:hover, textarea:hover {
box-shadow: 0 0 5px 0 #095484;
}
input[type="date"]::-webkit-inner-spin-button {
display: none;
}
input[type="time"]::-webkit-inner-spin-button {
margin: 2px 22px 0 0;
}
.item i, input[type="date"]::-webkit-calendar-picker-indicator {
position: absolute;
font-size: 20px;
color: #a9a9a9;
}
.item i {
right: 1%;
top: 30px;
z-index: 1;
}
[type="date"]::-webkit-calendar-picker-indicator {
right: 0;
z-index: 2;
opacity: 0;
cursor: pointer;
}
.btn-block {
margin-top: 20px;
text-align: center;
}
button {
width: auto;
padding: 10px;
border: none;
-webkit-border-radius: 5px;
-moz-border-radius: 5px;
border-radius: 5px;
background-color: #095484;
font-size: 16px;
color: #fff;
cursor: pointer;
}
button:hover {
background-color: #0666a3;
}
@media (min-width: 568px) {
.name-item, .city-item {
display: flex;
flex-wrap: wrap;
justify-content: space-between;
}
.name-item input, .city-item input {
width: calc(50% - 20px);
}
.city-item select {
width: calc(50% - 8px);
}
}
</style>
</head>
<body>
<div class="testbox">
<form action="/">
<h1>Pharmacy Complaint Form</h1>
<div class="item">
<p>Complainant's Name</p>
<div class="name-item">
<input type="text" name="name" placeholder="First" />
<input type="text" name="name" placeholder="Last" />
</div>
</div>
<div class="item">
<p>Address</p>
<input type="text" name="name" placeholder="Street address"/>
<input type="text" name="name" placeholder="Street address line 2"/>
<div class="city-item">
<input type="text" name="name" placeholder="City" />
<input type="text" name="name" placeholder="Region" />
<input type="text" name="name" placeholder="Postal / Zip code" />
<select>
<option value="">Country</option>
<option value="1">Russia</option>
<option value="2">Germany</option>
<option value="3">France</option>
<option value="4">Armenia</option>
<option value="5">USA</option>
</select>
</div>
</div>
<div class="item">
<p>Email</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Telephone number where you can be reached</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Incident Date</p>
<input type="date" name="name" required/>
<i class="fas fa-calendar-alt"></i>
</div>
<div class="item">
<p>Incident Time</p>
<input type="time" name="name" required/>
<i class="fas fa-clock"></i>
</div>
<div class="item">
<p>What best describes the type of problem encountered</p>
<select>
<option value="">Please select</option>
<option value="1">Dispensing Error</option>
<option value="2">Illegal Dispensing</option>
<option value="3">Fraud</option>
<option value="4">Impairment/Diversion</option>
<option value="5">Unethical Conduct</option>
<option value="6">Regards Prescriber</option>
<option value="6">Other</option>
</select>
</div>
<div class="item">
<p>Pharmacy Personnel Involved</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Pharmacy Involved</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>Complaint filed on behalf of</p>
<input type="text" name="name"/>
</div>
<div class="item">
<p>What happened? Be as specific as possible, including dates, names, etc.</p>
<textarea rows="5"></textarea>
</div>
<div class="btn-block">
<button type="submit" href="/">Send Complaint</button>
</div>
</form>
</div>
</body>
</html>