Simpex Admin

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<div class="clicktab container">
<div class="row">
<div class="col-sm-6"><a href="#" class="tab1">ADVERSE EVENT REPORTING</a> <p><a href="#" data-toggle="modal" data-target="#ADVERSE"><u>Click on</u></a> the tab above report any adverse events or undesirable experience, sometimes known as side effects, associated with use of our medicines.</p></div>

<div class="modal-header">
        <h4 class="modal-title">ADVERSE EVENT REPORTING</h4>
        <button type="button" class="close" data-dismiss="modal">×</button>
      </div>

<div class="modal-body">
        
<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Name of Reportee <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Phone Number <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Email Address <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Country <b>*</b>  :</label> 
<select class="form-control">
<option>--Please Select--</option>
</select>
</div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>ADR Details <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Product Name <b>*</b>  :</label>  <input type="text" name="" class="form-control"></div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Batch Number <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Doctor Name/ Hospital <b>*</b>  :</label>  <input type="text" name="" class="form-control"></div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Using this product Since <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Attchment options for (jpg, word, pdf etc) document <b>*</b>  :</label>  <input type="file" name="" class="form-control"></div></div>
</div>

<button type="submit" name="" class="btn btn-danger">Submit</button>

</div>

</div>
  </div>
</div>

<div class="col-sm-6"><a href="#" class="tab2">PRODUCT QUALITY COMPLAINT REPORTING</a> <p><a href="#" data-toggle="modal" data-target="#QUALITY"><u>Click on</u></a> the tab above to report any complaints regarding the quality of our medicines.</p></div>

<div class="modal-header">
        <h4 class="modal-title">PRODUCT QUALITY COMPLAINT REPORTING</h4>
        <button type="button" class="close" data-dismiss="modal">×</button>
      </div>

<div class="modal-body">
        <form action="" method="get" class="enquiryform">
<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Name of Reportee <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Phone Number <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Email Address <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Country <b>*</b>  :</label> 
<select class="form-control">
<option>--Please Select--</option>
</select>
</div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Complaint Details <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Product Name <b>*</b>  :</label>  <input type="text" name="" class="form-control"></div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Batch Number <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Mfg date / exp date  <b>*</b>  :</label>  <input type="text" name="" class="form-control"></div></div>
</div>

<div class="row">
<div class="col-sm-6"><div class="form-group"><label>Doctor Name/ Hospital  <b>*</b> :</label> <input type="text" name="" class="form-control"></div></div>
<div class="col-sm-6"><div class="form-group"><label>Attchment options for (jpg, word, pdf etc) document <b>*</b>  :</label>  <input type="file" name="" class="form-control"></div></div>
</div>

<button type="submit" name="" class="btn btn-danger">Submit</button>

</form>
      </div>

</div>
  </div>
</div>

</div>
</div>

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