Darrel Israel
66 lines
2.9 KiB
PHP
66 lines
2.9 KiB
PHP
<link rel="stylesheet" href="assets\css\number.css">
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<form action="savepatient.php" method="POST">
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<fieldset class="custom-fieldset">
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<legend>
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<h1 style="text-align: center;"><b>Patient Information</b></h1>
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</legend>
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<div class="modal-body">
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<div class="nameage">
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<label for="firstName">First Name:</label>
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<input class="form-control" type="text" id="firstName" name="fname" placeholder="First Name" >
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</div>
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<div class="nameage"><br>
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<label for="middleName">Middle Name:</label>
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<input class="form-control" type="text" id="middleName" name="mname" placeholder="Middle Name">
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</div>
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<div class="nameage"><br>
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<label for="lastName">Last Name:</label>
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<input class="form-control" type="text" id="lastName" name="lname" placeholder="Last Name">
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</div>
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<div class="nameage"><br>
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<label for="age">Age:</label>
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<input class="form-control" type="number" id="age" name="age" placeholder="Ex. 15" min="0" max="9999999999" inputmode="numeric" pattern="[0-9]*">
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</div>
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<div class="nameage"><br>
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<label for="sex">Sex:</label>
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<span style="margin-right: 10px;"></span>
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<input type="radio" name="sex" id="male" value="male" checked>
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<label for="male">Male</label>
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<!-- Add a CSS style to create space -->
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<span style="margin-right: 10px;"></span>
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<input type="radio" name="sex" id="female" value="female">
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<label for="female">Female</label>
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<br>
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<br>
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</div>
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<div class="nameage">
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<label for="civilStatus">Civil Status:</label>
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<input class="form-control" type="text" id="civilStatus" name="civilStatus" placeholder="Ex. Single">
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</div>
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<div class="nameage"><br>
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<label for="civilStatus">Phone Number:</label>
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<input class="form-control" type="number" id="phonenum" name="phonenum" placeholder="Ex. 0912345678" min="0" max="9999999999" inputmode = "numeric" pattern="[0-9]*">
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</div>
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<div class="nameage"><br>
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<label for="address">Address:</label>
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<input class="form-control" type="text" id="address" name="address" placeholder="Iloilo City">
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</div>
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<div class="nameage"><br>
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<label for="dateOfBirth">Date Of Birth:</label><br>
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<input type="date" id="dateOfBirth" name="dateOfBirth">
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</div>
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</div>
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</fieldset>
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<div class="modal-footer">
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<button type="submit" class="btn btn-primary" name="btnSavePatient">Save</button>
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</div>
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</fieldset>
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</form> |