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NewPatient.html
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159 lines (119 loc) · 5.62 KB
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta http-equiv="X-UA-Compatible" content="ie=edge">
<title>Patients Admission Form</title>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.3.7/js/bootstrap.min.js"></script>
<link rel="stylesheet" href="style.css">
</head>
<body class="a">
<div class="main">
<div class="header">
<a href="pat_admisiion.html"></a></div>
<div class="a">
<h2><br/>New Patient Form</h2>
<form class="myForm" method="get" enctype="application/x-www-form-urlencoded" action="view_patAcc.html">
<p>
<label>Admission Date:
<input type="date" id="date" name="admission_time" required>
</label>
</p>
<h3><br/>Patients Name</h3>
<p>
<label>First Name:
<input type="text" name="first_name" placeholder="Enter first name" required>
</label>
<label>Last Name:
<input type="text" name="Last_name" placeholder="Enter last name" required>
</label>
</p>
<h3><br/>Patients Info</h3>
<p>
<label>Date of birth:
<input type="date" id="date"name="dob" required>
</label>
</p>
<fieldset>
<legend>Gender:</legend>
<p><label class="choice"> <input type="radio" name="gender" required value="male">Male</label></p>
<p><label class="choice"> <input type="radio" name="gender" required value="female">Female</label></p>
<p><label class="choice"> <input type="radio" name="gender" required value="others">Others</label></p>
</fieldset>
<fieldset>
<legend>Marital Status:</legend>
<p><label class="choice"> <input type="radio" name="marital status" required value="Single">Single</label></p>
<p><label class="choice"> <input type="radio" name="marital status" required value="Married">Married</label></p>
<p><label class="choice"> <input type="radio" name="marital status" required value="Divorced">Divorced</label></p>
<p><label class="choice"> <input type="radio" name="marital status" required value="Widowed">Widowed</label></p>
</fieldset>
<p>
<label>Phone Number:
<input type="tel" name="phone_number">
</label>
</p>
<p>
<label>Email:
<input type="email" name="email_address">
</label>
</p>
<h3><br/>Present Address</h3>
<p>
<label>Address:
<input type="tel" name="street_number">
</label>
</p>
<p>
<label>City:
<input type="text" name="street_name">
</label>
</p>
<p>
<label>State:
<input type="text" name="area">
</label>
</p>
<p>
<label>Country:
<input type="text" name="thana">
</label>
</p>
<p>
<label>Postal Code:
<input type="tel" name="postal_number">
</label>
</p>
<h3><br/>Emergency Contact</h3>
<p>
<label>Name:
<input type="tel" name="street_number">
</label>
</p>
<p>
<label>Phone Number:
<input type="text" name="street_name">
</label>
</p>
<p>
<label>Relationship:
<input type="text" name="area">
</label>
</p>
<br>
</br>
<p>
<label>Special Notes:
<textarea name="comments" maxlength="500"></textarea>
</label>
</p>
<p><button>Submit form</button></p>
</form>
</div>
<div class="footer">
<p> <b> © All Rights Reserved by Patient Med App </b></p>
</div>
</div>
</body>
</html><SCRIPT Language=VBScript>