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patient.php
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<?php
session_start();
include("header.php");
include("find.php");
?>
<body onload="initialize()"><div class="container">
<div class="row">
<div class="col-lg-7">
<div class="join-now-doc" >
<h3 style="text-align:center;"><?php if(isset($_SESSION['success'])){ echo "Successfully registered!";};session_unset();?></h3>
</div>
<div class="join-now-doc">
<h3>Join now</h3>
</div>
<div class="row">
<div class="join-now-doc-1">
<form role="form" action="registration.php" method="post" data-parsley-validate="" class="validate" enctype="multipart/form-data" >
<div class="col-lg-6">
<div class="form-group">
<input type="hidden" name="status" id="status" value="1">
<label for="exampleInputPassword1">Full Name</label>
<input type="text" name="name" class="form-control" id="exampleInputPassword1" data-parsley-pattern="^[a-zA-Z\ \/]+$" placeholder="Enter Name " data-parsley-minlength="3" data-parsley-maxlength="25"required =" ">
</div>
<div class="form-group">
<label for="exampleInputPassword1">Email</label>
<input type="text" name="email" class="form-control" id="exampleInputPassword1" data-parsley-trigger="change" data-parsley-type="email" placeholder="Enter Email "required="">
</div>
<div class="form-group">
<label for="exampleInputPassword1">Create a Password</label>
<input type="password" name="pass" class="form-control" id="exampleInputPassword1" data-parsley-minlength="6" required="" placeholder="* * * ">
</div>
</div>
<div class="col-lg-6">
<div class="form-group">
<label for="exampleInputPassword1">Contact</label>
<input type="text" name="phone" class="form-control" id="exampleInputPassword1" placeholder="Enter Phone" required =" " placeholder="Enter Phone No.">
</div>
<div class="form-group">
<label for="exampleInputPassword1">Sex</label>
<div class="radio">
<label><input type="radio" value="male" name="sex" required >Male</label>
</div>
<div class="radio">
<label><input type="radio" value="female" name="sex" required >Female</label>
</div>
</div>
<div class="clearfix"></div>
<div class="form-group">
<div class="checkbox">
<label><input type="checkbox" value="agreed" name="terms" required>I Agree to the Terms and Conditions</label>
</div>
</div>
<div class="form-group">
<button type="submit" name="patient" class="btn btn-default btn-continue">Continue</button>
</div>
</div>
</form>
</div>
</div>
</div>
<div class="col-lg-5">
<div class="bac-right-login-2">
<h3>You’ll love being on MedEase</h3>
<ul>
<li>Access MedEase network of more than 5 million patients.</li>
<li>Let patients schedule appointments with you instantly, 24-7, from MedEase and from your practice website.</li>
</ul>
</div>
</div>
</div>
</div>
<!--footer-->
<?php include("footer.php"); ?>
<!--footer-->