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database.html
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<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap-icons@1.7.1/font/bootstrap-icons.css">
<title>Patient Details</title>
<style>
.form-group{
margin-top: 3%;
margin-bottom: 5%;
margin-right: 15%;
margin-left: 15%;
background-color: whitesmoke;
height: 1050px;
padding-top: 2%;
}
.btn{
color: black;
font: bolder;
background-color: green;
height: 40px;
width: 100px;
padding: 0px;
font-size: larger;
}
td {
width:800px;
/*text-align:center;
border:1px solid black;*/
padding:5px;
height: 40px;
}
</style>
</head>
<body>
<div class="form-group">
<h2 style="text-align:center;color: green;">Patient Information(Required)</h2>
<form action="patient.php" method="POST">
<table style="font-size: larger;margin-left: 20%; ">
<td>Patient Name<sup style="color:red;">*</sup></td><br>
<tr>
<td><input type="text" name="fname" placeholder="First Name" required="required"></td>
<td><input type="text" name="lname" placeholder="Last Name" required="required"></td>
</tr>
<tr>
<td>Patient Date of Birth<sup style="color:red;">*</sup></td>
<td>Patient Gender<sup style="color:red;">*</sup></td>
</tr>
<tr>
<td><input type="Date" name="dateOfBirth" placeholder="MM/DD/YYYY" required="required"></td>
<td><input type="radio" name="gender_male" value="male">Male<input type="radio" name="gender_male" value="female">Female</td>
</tr>
<tr>
<td>Patient Social Security Number<sup style="color:red;">*</sup></td>
<td>Patient Marital Status<sup style="color:red;">*</sup></td>
</tr>
<tr>
<td><input type="text" name="snumber"></td>
<td><input type="radio" name="single" value="single">Single<input type="radio" name="single" value="married">Married</td>
</tr>
<tr>
<td>Alternative Patient phone Number<sup style="color:red;">*</sup></td>
<td>Patient phone Number<sup style="color:red;">*</sup></td>
</tr>
<tr>
<td><input type="text" name="number" required="required"></td>
<td><input type="text" name="mob_number" required="required"></td>
</tr>
<tr>
<td>Patient Address of Residence<sup style="color:red;">*</sup></td>
<td>Patient Email<sup style="color:red;">*</sup></td>
</tr>
<tr>
<td><textarea name="address"></textarea></td>
<td><input type="text" name="email"></td>
</tr>
<tr>
<td><input type="text" name="district" placeholder="District" required=""></td>
<td><input list="state" name="state" placeholder="State" required="required">
<datalist id="state">
<option value="Andhra Pradesh">
<option value="Arunachal Pradesh">
<option value="Assam">
<option value="Bihar">
<option value="Chhattisgarh ">
<option value="Goa">
<option value="Gujarat">
<option value="Haryana">
<option value="Himachal Pradesh">
<option value="Jharkhand">
<option value="Karnataka">
<option value="Kerala">
<option value="Madhya Pradesh">
<option value="Maharashtra">
<option value="Manipur">
<option value="Meghalaya">
<option value="Mizoram">
<option value="Nagaland">
<option value="Odisha">
<option value="Punjab">
<option value="Rajasthan">
<option value="Sikkim">
<option value="Tamil Nadu">
<option value="Telangana">
<option value="Tripura">
<option value="Uttar Pradesh">
<option value="Uttarakhand">
<option value="West Bengal">
</datalist></td>
</td>
</tr>
<tr>
<td><input type="number" name="pin" placeholder="Pin Code/Zip Code" required="required"></td>
<td><input list="country" name="country" placeholder="country" required="required">
<datalist id="country">
<option value="India">
<option value="China">
<option value="U.S">
<option value="U.S.A">
<option value="Pakistan">
</datalist></td>
</tr>
<tr>
<td>Appoinment Date<sup style="color:red">*</sup></td>
<td>Choose Image<sup style="color:red;"></sup></td>
</tr>
<tr>
<td><input type="date" name="date" required="required"></td>
<td><input type="file" name="image"><td>
</tr>
<tr>
<td>Appoinment Time<sup style="color:red">*</sup></td>
<td>Doctor Name<sup style="color:red;">*</sup></td>
</tr>
<tr>
<td><input type="time" name="time" required="required"></td>
<td><input type="text" name="doctor-name"></td>
</tr>
<tr>
<td>Free💰</td>
</tr>
<tr>
<td>Free<sup style="color:red;">*</sup><input type="radio" name="fees">Paid<input type="radio" name="fees"></td>
<td><button type="submit" name="btn" value="btn" class="btn btn-warning">SUBMIT</button></td>
</tr>
</table>
</form>
</div>
</body>
</html>