お問い合わせフォーム

<!DOCTYPE html> <html lang="ja" class="h-100"> <head>  <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1">  <link rel="stylesheet" href="/static/base/bootstrap.min.css"> <link rel="stylesheet" href="/static/base/bootstrap-icons.css"> <link rel="stylesheet" href="/static/base/base.css"> <link rel="icon" href="/base/favicon.ico">  <link rel="shortcut icon" href="/base/favicon.ico">  <meta name="google-site-verification" content="JCo_BrZbDhGDOdSsaIQwUrKfa1vW6oaJ4T6UtSGi0c0" /> <link rel="stylesheet" href="/static/Inquiry/css/Inquiry.css"> <link rel="stylesheet" href="/static/Inquiry/css/input.css">  <title>お問い合わせフォーム</title> </head> <body class="d-flex flex-column h-100"> <header class="bg-light border-bottom mb-4"> <div class="container pb-3 mx-auto" style="max-width: 960px;"> <div class="row"> <div class="col-sm-1 pt-2"> <a href="https://www.umin.ac.jp/"><img class="img-fluid" src="/static/base/icon.gif" alt="医学情報・医療情報　UMIN"/></a> </div> <div class="col-sm-9"> <h2>お問い合わせフォーム </h2> </div> <div class="col-sm-2 pt-2"> <ul class="list-unstyled"> <li><a href="https://www.umin.ac.jp/"><i class="bi bi-house"></i>トップページ</a></li> </ul> </div> </div> </div> </header> <div class="container mx-auto" style="max-width: 960px;">  <div class="container background-gray border border-secondary rounded p-3"> <div class="my-4"><b>下記の各項目をご確認の上、ページ下部にある【送信確認】ボタンを押してください。</b></div> <form method="POST" id="inquiryForm" enctype="multipart/form-data"> <input type="hidden" name="csrfmiddlewaretoken" value="nQ5gLl5KVgOl653JkS53Ib8Hux29GFPsrDL2Qikwj1OOipd87aEYFVeDvHKYZeuH"> <table class="container table table-light table-bordered"> <tr> <th class="col-3 background-purple">お問い合わせサービス名</th> <td class="col-8 background-white text-primary">ARIAサービス</td> </tr> <tr> <th class="col-3 background-purple">アクセス元</th> <td class="col-8 background-white text-primary">不明 (8.222.208.146)</td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_name">氏名（漢字）</label> <span class="text-danger">【必須】</span> </th> <td class="col-8 background-white text-primary"> <input type="text" name="inquiry_name" class="form-control" placeholder="例：UMIN 太郎" required id="id_inquiry_name"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_text_field_0">氏名（かな）</label> <span class="text-danger">【必須】</span> </th> <td class="col-8 background-white text-primary"> <input type="text" name="inquiry_text_field_0" class="form-control" placeholder="例：ゆーみんたろう" required id="id_inquiry_text_field_0"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_text_field_1">UMIN ID</label> </th> <td class="col-8 background-white text-primary"> <input type="text" name="inquiry_text_field_1" class="form-control" placeholder="例：ggg-kk（ハイフンを含む英小文字と数字で構成された文字列）" id="id_inquiry_text_field_1"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_required_email_field">Eメールアドレス</label> <span class="text-danger">【必須】</span> </th> <td class="col-8 background-white text-primary"> <input type="text" name="inquiry_required_email_field" class="form-control" placeholder="例：〇〇@〇〇.co.jp" required id="id_inquiry_required_email_field"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_confirm_email_field">Eメールアドレス(確認用)</label> <span class="text-danger">【必須】</span> </th> <td class="col-8 background-white text-primary"> <input type="text" name="inquiry_confirm_email_field" class="form-control" placeholder="例：〇〇@〇〇.co.jp" onpaste="return false" autocomplete="off"" required id="id_inquiry_confirm_email_field"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_text_field_2">所属</label> <span class="text-danger">【必須】</span> </th> <td class="col-8 background-white text-primary"> <input type="text" name="inquiry_text_field_2" class="form-control" placeholder="例：大学病院医療情報ネットワークセンター" required id="id_inquiry_text_field_2"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_textarea_field_0">お問い合わせ内容</label> <span class="text-danger">【必須】</span> </th> <td class="col-8 background-white text-primary"> <textarea name="inquiry_textarea_field_0" cols="40" rows="10" class="form-control" placeholder="例：〇〇のページで〇〇をしようとしたら、〇〇と表示された" required id="id_inquiry_textarea_field_0"> </textarea> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_file_field_0">添付ファイル1</label> </th> <td class="col-8 background-white text-primary"> <input type="file" name="inquiry_file_field_0" class="form-control" id="id_inquiry_file_field_0"> </td> </tr> <tr> <th class="col-3 background-purple"> <label for="id_inquiry_file_field_1">添付ファイル2</label> </th> <td class="col-8 background-white text-primary"> <input type="file" name="inquiry_file_field_1" class="form-control" id="id_inquiry_file_field_1"> </td> </tr> </table> <hr> <h4 class="text-center">フォームを確認し、[送信確認]ボタンを押して下さい。</h4> <div class="d-grid gap-2 col-8 mx-auto"> <button class="btn btn-primary btn-lg" id="submitButton" type="submit">送信確認</button> <span id="submit_warning_text" class="text-danger text-center"></span> </div> </form> </div> <script type="text/javascript" src="/static/Inquiry/js/input.js"></script> </div> <footer class="footer mt-auto py-3 bg-light border-top"> <div class="container mx-auto" style="max-width: 960px;">  <div class="row"> <p class="float_clear"><img src="/static/base/foot.gif" alt="footer" style=" max-width:100%; height:auto" /></p> <p>Copyright © University hospital Medical Information Network (UMIN) Center</p> </div> </div> </footer> <script src="/static/base/bootstrap.bundle.min.js"></script> </body> </html>

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お問い合わせフォーム