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@@ -25,9 +25,11 @@
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<input type="text" name="medicareNumber" class="form-control" placeholder="Medicare Number" required>
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</div>
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<div class="form-group mb-3">
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- <input type="text" name="ssn" class="form-control" placeholder="SSN" required>
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+ <input type="tel" name="cellNumber" class="form-control" placeholder="Cell Number">
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+ </div>
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+ <div class="form-group mb-3">
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+ <input type="email" name="emailAddress" class="form-control" placeholder="Email Address">
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</div>
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-
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<button type="submit" class="btn btn-primary btn-block mx-auto w-50 mt-4 mb-2">Check In</button>
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</form>
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<script>
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