Darrel Israel
97 lines
3.8 KiB
PHP
97 lines
3.8 KiB
PHP
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css">
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<link rel="stylesheet" href="assets\css\number.css">
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<form action="saveuser.php" method="POST">
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<fieldset class="custom-fieldset">
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<legend>
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<h1><b>Add User</b></h1>
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</legend>
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<div>
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<br>
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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>
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<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>
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<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>
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<br>
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<label for="phoneNum">Address:</label>
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<input class="form-control" type="text" id="Address" name="address" placeholder="Address">
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</div>
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<div>
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<br>
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<label for="phoneNum">Phone Number:</label>
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<input class="form-control" type="number" id="phoneNum" name="phonenum" placeholder="Ex. 09123456789" min="0" max="9999999999" inputmode="numeric">
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</div>
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<div>
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<br>
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<label for="userPos">User Position:</label>
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<br>
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<input type="radio" name="UserPos" id="sec" value="isSec" checked>
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<label for="sec">Secretary</label>
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<input type="radio" name="UserPos" id="doctor" value="isDoc">
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<label for="doctor">Doctor</label>
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</div>
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<div id="specializationDiv">
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<br>
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<label for="specialization">Specialization:</label>
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<input class="form-control" type="text" id="specialization" name="specialization" placeholder="Ex. General Medicine">
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</div>
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<div id="licenseDiv">
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<br>
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<label for="licno">License Number:</label>
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<input class="form-control" type="number" id="licno" name="licno" placeholder="Ex. 123456789 " inputmode="numeric">
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</div>
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<div>
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<br>
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<label for="username">User Name:</label>
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<input class="form-control" type="text" id="username" name="username" placeholder="User Name">
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</div>
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<div>
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<br>
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<div>
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<label for="userPass">Password:</label>
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<div class="password-input-container">
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<input class="form-control" type="password" id="userPass" name="userPass" placeholder="Password">
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<button id="togglePassword" type="button" onclick="togglePasswordVisibility('userPass', 'eyeIcon')">
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<i id="eyeIcon" class="fa fa-eye" aria-hidden="true"></i>
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</button>
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</div>
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</div>
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<div>
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<br>
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<label for="confirmUserPass">Confirm Password:</label>
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<div class="password-input-container">
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<input class="form-control" type="password" id="confirmUserPass" name="confirmUserPass" placeholder="Confirm Password">
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<button id="togglePassword" type="button" onclick="toggleConfPasswordVisibility('confirmUserPass', 'eyeIconConfirm')">
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<i id="eyeIconConfirm" class="fa fa-eye" aria-hidden="true"></i>
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</button>
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</div>
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</div>
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<div class="modal-footer">
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<button type="submit" class="btn btn-primary" name="btnSaveUser">Save</button>
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</div>
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</fieldset>
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</form>
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<script src="assets/js/a.js"></script> |