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patient-sign-up.html
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patient-sign-up.html
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<!DOCTYPE html>
<html>
<head>
<meta charset="UTF-8">
<title>Patient Sign up</title>
<link rel="stylesheet" type="text/css" href="style.css">
</head>
<body>
<header>
<h1>Patient Sign up</h1>
</header>
<main>
<form action = "patient-sign-up.php" method = "post">
<section>
<header>
<h2>Personal Details</h2>
</header>
<label for="first_name">First Name:</label>
<input type="first_name" id ="first_name" name="first_name" required>
<br><br>
<label for="last_name">Last Name:</label>
<input type="last_name" id ="last_name" name="last_name" required>
<br><br>
<label for="dob">Date of Birth:</label>
<input type="date" id ="dob" name="dob" required>
<br><br>
<label for="gender">Gender:</label>
<select id="gender" name="gender">
<option value="">Select your gender</option>
<option value="male">Male</option>
<option value="female">Female</option>
<option value="other">Other</option>
</select>
<br><br>
<div style="text-align:justify;">
<label for="disabilities">Enter Impairments applicable:</label>
</div>
<textarea id="disabilities" name="disabilities" placeholder="Give a brief description of your impairments. Detail how long you have been dealing with the impairments, and the medications that you are currently taking. Add any access arrangements you require." style="height: 50px; width: 500px;" required></textarea>
<br><br>
<div style="text-align:justify;">
<label for="description"> Description: </label>
</div>
<textarea id="description" name="description" placeholder="Give a brief description of your needs. Detail your symptoms how long you have been experiencing them; what kind of doctor you are looking for." style="height: 50px; width: 500px;" required></textarea>
<br><br>
</section>
<section>
<header>
<h2>Account Details</h2>
</header>
<label for="phone">Contact number:</label>
<input type="tel" id="phone" name="phone" pattern="[0-9]{8}" required><br><br>
<label for="email">Email:</label>
<input type="email" id ="email" name="email" placeholder="xyz@gmail.com" required>
<br><br>
<label for="password">Create Password:</label>
<input type="password" id="pwd" name="pwd" required>
<br><br>
</section>
<!-- <a href="patient-view.html" id="submit" name="submit" class="button-89">Sign Up</a> -->
<input type="submit" id="submit" name="submit" value="Sign Up">
<input type="reset" value="Reset">
</form>
</main>
</body>
</html>