forked from Ratan5545/Hospital_management_system
-
Notifications
You must be signed in to change notification settings - Fork 0
/
patient.html
115 lines (82 loc) · 3.55 KB
/
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
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
<!DOCTYPE html>
<html lang="en" >
<head>
<meta charset="UTF-8">
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/normalize/5.0.0/normalize.min.css">
<link rel="stylesheet" href="./style.css">
</head>
<body>
<!-- Patient Registeration -->
<div class="container">
<div class="title">Patient Registration</div>
<div class="content">
<form method="POST" action="insert_patient.PHP" >
<div class="user-details">
<div class="input-box">
<span class="details">Patient Id</span>
<input type="text" placeholder="Enter Patient Id" required name="patient_id">
</div>
<div class="input-box">
<span class="details">Room Id</span>
<input type="text" placeholder="Enter Room Id" required name="room_id">
</div>
<div class="input-box">
<span class="details">First Name</span>
<input type="text" placeholder="Enter your first name" required name="firstname">
</div>
<div class="input-box">
<span class="details">Last Name</span>
<input type="text" placeholder="Enter your last name" required name="lastname">
</div>
<div class="input-box">
<span class="details">Email</span>
<input type="text" placeholder="Enter your email" required name="email">
</div>
<div class="input-box">
<span class="details">Phone </span>
<input type="text" placeholder="Enter your number" required name="phone">
</div>
<div class="input-box">
<span class="details">StreetAddress</span>
<input type="text" placeholder="Enter your Address" required name="address">
</div>
<div class="input-box">
<span class="details">City</span>
<input type="text" placeholder="Enter your City" required name="city">
</div>
<div class="input-box">
<span class="details">State</span>
<input type="text" placeholder="Enter your state" required name="state">
</div>
<div class="input-box">
<span class="details">Zipcode</span>
<input type="text" placeholder="Enter your zipcode" required name="zipcode">
</div>
<div class="input-box">
<span class="details">Allergies</span>
<input type="text" placeholder="Enter your allergy" required name="allergies">
</div>
<div class="input-box">
<span class="details">Chronic Disease</span>
<input type="text" placeholder="Chronic disease" required name="chronicdiseases">
</div>
<div class="input-box">
<span class="details">OtherHealthConcerns</span>
<input type="text" placeholder="OtherHealthConcerns" required name="OtherHealthConcerns">
</div>
<div class="input-box">
<span class="details">Policy Number</span>
<input type="text" placeholder="Enter Policy Number" required name="policy_number">
</div>
<div class="input-box">
<span class="details">Pharmacy Id</span>
<input type="text" placeholder="Enter Pharmacy Id" required name="PharmacyId">
</div>
</div>
<div class="button">
<input type="submit" value="Register">
</div>
</form>
</div>
</body>
</html>