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insertPatient.html
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insertPatient.html
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<!doctype html>
<html lang="en">
<head>
<title>Welcome To Fill Red</title>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1">
<meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=0">
<!-- MAIN CSS -->
<link rel="stylesheet" href="./css/index.css">
<link rel="stylesheet" href="./css/extra.css">
<!-- GOOGLE FONTS -->
<link href="https://fonts.googleapis.com/css?family=Source+Sans+Pro:300,400,600,700" rel="stylesheet">
<!--Font FontAwesome -->
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.5.0/css/all.css" integrity="sha384-B4dIYHKNBt8Bc12p+WXckhzcICo0wtJAoU8YZTY5qE0Id1GSseTk6S+L3BlXeVIU" crossorigin="anonymous">
<!-- icon-->
<link rel="icon" type="image/png" sizes="96x96" href="./logo.png">
</head>
<body>
<div class="container">
<div class="row text-center">
<h1 class="heading">Welcome To Fill Red Organisation</h1>
</div>
<div class="row text-center">
<center><img class="head-img" src="blood-bank.png"></center>
</div>
<div class="row">
<span class=""><a href="./index.php">Home</a>/<a href="./placeRequest">Request Blood</a>/Register as a Patient</span>
</div>
<div class="row card black-text border">
<div class="black-text padding">
<h2 class="heading">Register as a Patient</h2>
<div class="row">
<form action="insertpatient.php" method="post" class="align-column">
<div class="align-row">
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="pid" placeholder="Patient Id" hidden="hidden">
</div>
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="pFNAME" placeholder="Patient Name" required>
</div>
</div>
<div class="align-row">
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="PLNAME" placeholder="Last Name" required>
</div>
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="pAge" placeholder="Age" required>
</div>
</div>
<div class="align-row">
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="p_pincode" placeholder="PIN Code" required>
</div>
<div class="col margin-auto">
<select name="pSEX" required id="pSEX" class="form-control form-text">
<option>SEX</option>
<option value="MALE">MALE</option>
<option value="FEMALE">FEMALE</option>
<option value="OTHERS">OTHERS</option>
</select>
</div>
</div>
<div class="align-row">
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="pPhoneNo" placeholder="Phone Number" required>
</div>
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="pAddress" placeholder="Address" required>
</div>
</div>
<div class="align-row">
<div class="col margin-auto">
<input class="form-control form-text" type="text" name="p_city" placeholder="City" required>
</div>
<div class=" col margin-auto">
<select class="form-control form-text" name="pBloodGroup" required id="pBloodGroup" required>
<option>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="AB+">AB+</option>
<option value="AB-">AB-</option>
<option value="O+">O+</option>
<option value="O-">O-</option>
</select>
</div>
</div>
<div class="align-row">
<div class="col-1 margin-auto">
<input class="red-button" type="submit" value="Submit">
</div>
<div class="col-1 margin-auto">
*Terms and condition apply
</div>
</div>
</form>
</div>
</div>
</div>
</div>
</body>
<html>