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patientreg.html
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patientreg.html
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<!DOCTYPE html>
<!-- Designined by CodingLab - youtube.com/codinglabyt -->
<html lang="en" dir="ltr">
<head>
<meta charset="UTF-8">
<title> Patient reg form</title>
<link rel="stylesheet" href="reg.css">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
</head>
<body>
<div >
<a href="Home/index.html">
<img width="40px;" height="40px;" style="margin-left: -600%;" src="Home/images/back.png" alt="back">
</a>
</div>
<div class="container">
<div class="title" style="">Patient_Registration</div>
<div class="content">
<form action="#">
<div class="user-details">
<div class="input-box">
<span class="details">Full Name</span>
<input type="text" placeholder="Enter your name" name="fullname"required>
</div>
<div class="input-box">
<span class="details">Email</span>
<input type="text" placeholder="Enter your email" name="email"required>
</div>
<div class="input-box">
<span class="details">Date of Birth</span>
<input type="date" placeholder="Enter your email" name="dob"required>
</div>
<div class="input-box">
<span class="details">Phone Number</span>
<input type="text" placeholder="Enter your number" name="conatct"required>
</div>
<div class="input-box">
<span class="details">Blood group</span>
<select class="select" name="bloodgroup" style="height: 65%;
width: 100%; max-height: 300px;border-radius:5px;border: 1px solid #ccc;">
<option style="color:gray;">--select--</option>
<option value="A">A</option>
<option value="B">B</option>
<option value="AB">AB</option>
<option value="O">0</option>
</select>
</div>
<div class="input-box">
<span class="details">Nationality</span>
<select class="" name="" style="height: 62%;
width: 100%; max-height: 300px;border-radius:5px;border: 1px solid #ccc;">
<option style="color:gray;">--select--</option>
<option value="afghan">Afghan</option>
<option value="albanian">Albanian</option>
<option value="algerian">Algerian</option>
<option value="american">American</option>
<option value="andorran">Andorran</option>
<option value="angolan">Angolan</option>
<option value="antiguans">Antiguans</option>
<option value="argentinean">Argentinean</option>
<option value="armenian">Armenian</option>
<option value="australian">Australian</option>
<option value="austrian">Austrian</option>
<option value="azerbaijani">Azerbaijani</option>
<option value="bahamian">Bahamian</option>
<option value="bahraini">Bahraini</option>
<option value="bangladeshi">Bangladeshi</option>
<option value="barbadian">Barbadian</option>
<option value="barbudans">Barbudans</option>
<option value="batswana">Batswana</option>
<option value="belarusian">Belarusian</option>
<option value="belgian">Belgian</option>
<option value="belizean">Belizean</option>
<option value="beninese">Beninese</option>
<option value="bhutanese">Bhutanese</option>
<option value="bolivian">Bolivian</option>
<option value="bosnian">Bosnian</option>
<option value="brazilian">Brazilian</option>
<option value="british">British</option>
<option value="bruneian">Bruneian</option>
<option value="bulgarian">Bulgarian</option>
<option value="burkinabe">Burkinabe</option>
<option value="burmese">Burmese</option>
<option value="burundian">Burundian</option>
<option value="cambodian">Cambodian</option>
<option value="cameroonian">Cameroonian</option>
<option value="canadian">Canadian</option>
<option value="cape verdean">Cape Verdean</option>
<option value="central african">Central African</option>
<option value="chadian">Chadian</option>
<option value="chilean">Chilean</option>
<option value="chinese">Chinese</option>
<option value="colombian">Colombian</option>
<option value="comoran">Comoran</option>
<option value="congolese">Congolese</option>
<option value="costa rican">Costa Rican</option>
<option value="croatian">Croatian</option>
<option value="cuban">Cuban</option>
<option value="cypriot">Cypriot</option>
<option value="czech">Czech</option>
<option value="danish">Danish</option>
<option value="djibouti">Djibouti</option>
<option value="dominican">Dominican</option>
<option value="dutch">Dutch</option>
<option value="east timorese">East Timorese</option>
<option value="ecuadorean">Ecuadorean</option>
<option value="egyptian">Egyptian</option>
<option value="emirian">Emirian</option>
<option value="equatorial guinean">Equatorial Guinean</option>
<option value="eritrean">Eritrean</option>
<option value="estonian">Estonian</option>
<option value="ethiopian">Ethiopian</option>
<option value="fijian">Fijian</option>
<option value="filipino">Filipino</option>
<option value="finnish">Finnish</option>
<option value="french">French</option>
<option value="gabonese">Gabonese</option>
<option value="gambian">Gambian</option>
<option value="georgian">Georgian</option>
<option value="german">German</option>
<option value="ghanaian">Ghanaian</option>
<option value="greek">Greek</option>
<option value="grenadian">Grenadian</option>
<option value="guatemalan">Guatemalan</option>
<option value="guinea-bissauan">Guinea-Bissauan</option>
<option value="guinean">Guinean</option>
<option value="guyanese">Guyanese</option>
<option value="haitian">Haitian</option>
<option value="herzegovinian">Herzegovinian</option>
<option value="honduran">Honduran</option>
<option value="hungarian">Hungarian</option>
<option value="icelander">Icelander</option>
<option value="indian">Indian</option>
<option value="indonesian">Indonesian</option>
<option value="iranian">Iranian</option>
<option value="iraqi">Iraqi</option>
<option value="irish">Irish</option>
<option value="israeli">Israeli</option>
<option value="italian">Italian</option>
<option value="ivorian">Ivorian</option>
<option value="jamaican">Jamaican</option>
<option value="japanese">Japanese</option>
<option value="jordanian">Jordanian</option>
<option value="kazakhstani">Kazakhstani</option>
<option value="kenyan">Kenyan</option>
<option value="kittian and nevisian">Kittian and Nevisian</option>
<option value="kuwaiti">Kuwaiti</option>
<option value="kyrgyz">Kyrgyz</option>
<option value="laotian">Laotian</option>
<option value="latvian">Latvian</option>
<option value="lebanese">Lebanese</option>
<option value="liberian">Liberian</option>
<option value="libyan">Libyan</option>
<option value="liechtensteiner">Liechtensteiner</option>
<option value="lithuanian">Lithuanian</option>
<option value="luxembourger">Luxembourger</option>
<option value="macedonian">Macedonian</option>
<option value="malagasy">Malagasy</option>
<option value="malawian">Malawian</option>
<option value="malaysian">Malaysian</option>
<option value="maldivan">Maldivan</option>
<option value="malian">Malian</option>
<option value="maltese">Maltese</option>
<option value="marshallese">Marshallese</option>
<option value="mauritanian">Mauritanian</option>
<option value="mauritian">Mauritian</option>
<option value="mexican">Mexican</option>
<option value="micronesian">Micronesian</option>
<option value="moldovan">Moldovan</option>
<option value="monacan">Monacan</option>
<option value="mongolian">Mongolian</option>
<option value="moroccan">Moroccan</option>
<option value="mosotho">Mosotho</option>
<option value="motswana">Motswana</option>
<option value="mozambican">Mozambican</option>
<option value="namibian">Namibian</option>
<option value="nauruan">Nauruan</option>
<option value="nepalese">Nepalese</option>
<option value="new zealander">New Zealander</option>
<option value="ni-vanuatu">Ni-Vanuatu</option>
<option value="nicaraguan">Nicaraguan</option>
<option value="nigerien">Nigerien</option>
<option value="north korean">North Korean</option>
<option value="northern irish">Northern Irish</option>
<option value="norwegian">Norwegian</option>
<option value="omani">Omani</option>
<option value="pakistani">Pakistani</option>
<option value="palauan">Palauan</option>
<option value="panamanian">Panamanian</option>
<option value="papua new guinean">Papua New Guinean</option>
<option value="paraguayan">Paraguayan</option>
<option value="peruvian">Peruvian</option>
<option value="polish">Polish</option>
<option value="portuguese">Portuguese</option>
<option value="qatari">Qatari</option>
<option value="romanian">Romanian</option>
<option value="russian">Russian</option>
<option value="rwandan">Rwandan</option>
<option value="saint lucian">Saint Lucian</option>
<option value="salvadoran">Salvadoran</option>
<option value="samoan">Samoan</option>
<option value="san marinese">San Marinese</option>
<option value="sao tomean">Sao Tomean</option>
<option value="saudi">Saudi</option>
<option value="scottish">Scottish</option>
<option value="senegalese">Senegalese</option>
<option value="serbian">Serbian</option>
<option value="seychellois">Seychellois</option>
<option value="sierra leonean">Sierra Leonean</option>
<option value="singaporean">Singaporean</option>
<option value="slovakian">Slovakian</option>
<option value="slovenian">Slovenian</option>
<option value="solomon islander">Solomon Islander</option>
<option value="somali">Somali</option>
<option value="south african">South African</option>
<option value="south korean">South Korean</option>
<option value="spanish">Spanish</option>
<option value="sri lankan">Sri Lankan</option>
<option value="sudanese">Sudanese</option>
<option value="surinamer">Surinamer</option>
<option value="swazi">Swazi</option>
<option value="swedish">Swedish</option>
<option value="swiss">Swiss</option>
<option value="syrian">Syrian</option>
<option value="taiwanese">Taiwanese</option>
<option value="tajik">Tajik</option>
<option value="tanzanian">Tanzanian</option>
<option value="thai">Thai</option>
<option value="togolese">Togolese</option>
<option value="tongan">Tongan</option>
<option value="trinidadian or tobagonian">Trinidadian or Tobagonian</option>
<option value="tunisian">Tunisian</option>
<option value="turkish">Turkish</option>
<option value="tuvaluan">Tuvaluan</option>
<option value="ugandan">Ugandan</option>
<option value="ukrainian">Ukrainian</option>
<option value="uruguayan">Uruguayan</option>
<option value="uzbekistani">Uzbekistani</option>
<option value="venezuelan">Venezuelan</option>
<option value="vietnamese">Vietnamese</option>
<option value="welsh">Welsh</option>
<option value="yemenite">Yemenite</option>
<option value="zambian">Zambian</option>
<option value="zimbabwean">Zimbabwean</option>
</select>
</div>
<!-- <div class="input-box">
<span class="details">Confirm Password</span>
<input type="text" placeholder="Confirm your password" name="cpassword"required>
</div> -->
<div class="input-box">
<span class="details">Image</span>
<input type="file" placeholder="Confirm your password" name="image" required>
</div>
<div class="input-box">
<span class="details">Password</span>
<input type="text" placeholder="Enter your password" name="password"required>
</div>
</div>
<div class="gender-details">
<input type="radio" name="gender" id="dot-1">
<input type="radio" name="gender" id="dot-2">
<input type="radio" name="gender" id="dot-3">
<span class="gender-title">Gender</span>
<div class="category">
<label for="dot-1">
<span class="dot one"></span>
<span class="gender">Male</span>
</label>
<label for="dot-2">
<span class="dot two"></span>
<span class="gender">Female</span>
</label>
<label for="dot-3">
<span class="dot three"></span>
<span class="gender">Prefer not to say</span>
</label>
</div>
</div>
<div class="button">
<input type="submit" value="Register">
</div>
</form>
</div>
</div>
</body>
</html>