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request.html
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request.html
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<!DOCTYPE html>
<html lang="en">
<head>
<title>REQUEST</title>
</head>
<style>
body{
background-repeat: no-repeat;
background-size: cover;
}
span{
color: red;
}
.container
{
position: absolute;
top:50%;
left:50%;
transform: translate(-50%,-50%);
display: flex;
flex-direction: column;
align-items: center;
background-color: #8dc8c9;
padding: 50px;
}
.btn{
position: absolute;
left: 290px;
top: 700px;
background-color: #5184a0; /* Green */
border: none;
color: white;
padding: 15px 16px;
text-align: center;
text-decoration: none;
font-size: 16px;
border-radius: 12px;
box-shadow: 0 8px 16px 0 rgba(0,0,0,0.2), 0 6px 20px 0 rgba(0,0,0,0.19);
}
.button1
{
position: absolute;
left: 110px;
top: 700px;
background-color: #5184a0; /* Green */
border: none;
color: white;
padding: 15px 16px;
text-align: center;
text-decoration: none;
font-size: 16px;
border-radius: 12px;
box-shadow: 0 8px 16px 0 rgba(0,0,0,0.2), 0 6px 20px 0 rgba(0,0,0,0.19);
}
</style>
<body background="bg.jpeg">
<div class="container">
<center>
<h1>REQUEST </h1>
<form action="request1.php" method="POST" enctype="multipart/form-data">
<table>
<tr><td><p><label for="aadhar"> <b>AADHAR NUMBER </b><span>*</span></label></p></td>
<td><p><input type="tel" name="aadhar" id="reason" maxlength="12" pattern="[0-9]{12}" title="Enter Adhar Number without spaces" required></p></td></tr>
<tr><td><p><label for="fullName"><b>FULL NAME</b> <span>*</span></label></p></td>
<td><p><input type="text" name="name" id="name" pattern="[a-zA-Z\s.]+" title="Special characters or numbers are not allowed " required></p></td></tr>
<tr><td><p><label for="blood group"><b>BLOOD GROUP </b><span>*</span></label></p></td>
<!-- <td><p><input type="text" name="gender" id="gender" required></p></td></tr> -->
<td><select name="bloodgroup" id="bloodgroup" required>
<option value="">SELECT BLOOD GROUP</option>
<option value="A+">A+</option>
<option value="A-">A-</option>
<option value="B+">B+</option>
<option value="B-">B-</option>
<option value="O+">O+</option>
<option value="O-">O-</option>
<option value="AB+">AB+</option>
<option value="AB-">AB-</option>
</select></td></tr>
<tr><td><p><label for="reason"><b>REASON</b><span>*</span></label></p></td>
<td><p><input type="text" name="reason" id="reason" pattern="[a-zA-Z\s]+" title="special characters are not allowed" required></p></td></tr>
<tr><td><p><label for="report"><b>REPORT</b><span>*</span></label></p></td>
<div class="form-group">
<td><p><input class="form-control" type="file" name="uploadfile" accept="image/png, image/jpg, image/jpeg" required /></p></td></tr>
</div>
<tr><td><p><label for="PHONE"><b>MOBILE 1</b> <span>*</span></label></p></td>
<td><p><input type="tel" name="phone" id="phone" minlength="13" maxlength="13" pattern="[\+]{1}[0-9]{12}" placeholder="+91**********" title="Enter phone number with country code " required></p></td></tr>
<tr><td><p><label for="mobile"><b>MOBILE 2</b> </label></p></td>
<td><p><input type="tel" name="mobile" id="phone" minlength="13" maxlength="13" pattern="[\+]{1}[0-9]{12}" placeholder="+91**********" title="Enter phone number with country code "></p></td></tr>
<tr><td><p><label for="emailAddress"><b> EMAIL</b><span>*</span></label></p></td>
<td><p><input type="email" name="email" id="emailAddress" pattern="[A-Za-z0-9._%+-]{6,}@[a-z0-9.-]+\.[a-z]{2,}$" title="enter valid email" required></p></td></tr>
<tr><td><p><label for="city"><b>CITY</b> </b><span>*</span></label></p></td>
<td><p><input type="text" name="city" id="city" pattern="[a-zA-Z.\s]+" title="No special characters are allowed" minlength="5" maxlength="50" required></p></td></tr>
<tr><td><p><label for="HOSPITAL"><b>HOSPITAL LOCATION</b> </b></label></p></td>
<td><p><input type="text" name="hloc" id="city" minlength="5" maxlength="50" title="No special characters are allowed" required></p></td></tr>
</table>
<button class='button1' type="submit" name ="submit">SUBMIT</button>
<p><form action="index.html"><button class='btn'>CANCEL</button></form></p>
</form>
</center>
</div>
</body>
</html>