-
Notifications
You must be signed in to change notification settings - Fork 0
/
enter_patient.html
95 lines (92 loc) · 5.12 KB
/
enter_patient.html
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
<!DOCTYPE html>
<html lang="en-ie">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0, shrink-to-fit=no">
<title>Enter Patient</title>
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap.min.css">
<link rel="stylesheet" href="https://fonts.googleapis.com/css?family=Montserrat:400,400i,700,700i,600,600i">
<link rel="stylesheet" href="assets/fonts/simple-line-icons.min.css">
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/baguettebox.js/1.10.0/baguetteBox.min.css">
<link rel="stylesheet" href="assets/css/vanilla-zoom.min.css">
<script src="https://www.gstatic.com/firebasejs/8.2.3/firebase-app.js"></script>
<script src="https://www.gstatic.com/firebasejs/8.2.3/firebase-database.js"></script>
</head>
<body>
<nav class="navbar navbar-light navbar-expand-lg fixed-top bg-white clean-navbar">
<div class="container"><a class="navbar-brand logo" href="#">Medi-Web</a><button data-bs-toggle="collapse" class="navbar-toggler" data-bs-target="#navcol-1"><span class="visually-hidden">Toggle navigation</span><span class="navbar-toggler-icon"></span></button>
<div class="collapse navbar-collapse" id="navcol-1">
<ul class="navbar-nav ms-auto">
<li class="nav-item"><a class="nav-link" href="index.html">Home</a></li>
<li class="nav-item"><a class="nav-link" href="faq.html">FAQ</a></li>
<li class="nav-item"><a class="nav-link" href="about-us.html">About Us</a></li>
<li class="nav-item"><a class="nav-link" href="contact-us.html">Contact Us</a></li>
<li class="nav-item"><a class="nav-link" href="welcome_doctor.html">Your Account</a></li>
<li class="nav-item"><a class="nav-link" href="index.html">Sign out</a></li>
</ul>
</div>
</div>
</nav>
<main class="page landing-page">
<section class="clean-block features">
<div class="container">
<div class="block-heading">
<h1>Enter Patient Information</h1>
<h2 class="text-info"></h2>
<p></p>
</div>
</div>
<section class="clean-block clean-form dark">
<div class="container">
<div class="block-heading">
<p>Please enter the patients information below whom you would like to register</p>
</div>
<form>
<div class="mb-3"><label class="form-label" for="name">Forename</label><input class="form-control item" type="text" id="name"></div>
<div class="mb-3"><label class="form-label" for="name-1">Surname</label><input class="form-control item" type="text" id="name-1"></div>
<div class="mb-3"><label class="form-label" for="email">Email</label><input class="form-control item" type="email" id="email"></div>
<div class="mb-3"><label class="form-label" for="age">Age (Numeric Only)</label><input class="form-control" type="number" id="age"></div>
<div class="form-check"><input class="form-check-input" type="radio" id="formCheck-1"><label class="form-check-label" for="formCheck-1">Male</label></div>
<div class="form-check"><input class="form-check-input" type="radio" id="formCheck-2"><label class="form-check-label" for="formCheck-2">Female</label></div><button class="btn btn-primary" type="submit">Register</button>
</form>
</div>
</section>
</section>
</main>
<footer class="page-footer dark">
<div class="container">
<div class="row">
<div class="col-sm-3 offset-xxl-1">
<h5>Get started</h5>
<ul>
<li><a href="index.html">Home</a></li>
<li><a href="registration.html">Sign up</a></li>
</ul>
</div>
<div class="col-sm-3 offset-xxl-1">
<h5>About us</h5>
<ul>
<li></li>
<li><a href="contact-us.html">Contact us</a></li>
<li><a href="about-us.html">About Us</a></li>
</ul>
</div>
<div class="col-sm-3 offset-xxl-1">
<h5>Support</h5>
<ul>
<li><a href="faq.html">FAQ</a></li>
<li><a href="contact-us.html">Help desk</a></li>
</ul>
</div>
</div>
</div>
<div class="footer-copyright">
<p>© 2021 Medi-Web</p>
</div>
</footer>
<script src="assets/bootstrap/js/bootstrap.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/baguettebox.js/1.10.0/baguetteBox.min.js"></script>
<script src="assets/js/vanilla-zoom.js"></script>
<script src="assets/js/theme.js"></script>
</body>
</html>