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Usersignup.html
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Usersignup.html
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<!DOCTYPE html>
<html lang="en">
<head>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/1.12.2/jquery.min.js"></script>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1">
<!-- The above 3 meta tags *must* come first in the head; any other head content must come *after* these tags -->
<title>SMART CLINIC User Sign up</title>
<meta name="description" content="Course files for the most awesome Bootstrap 3 course on Udemy.">
<meta name="author" content="Gobala Krishnan">
<!-- Bootstrap & Fontawesome -->
<link href="assets/css/bootstrap.css" rel="stylesheet">
<link href="assets/css/font-awesome.min.css" rel="stylesheet">
<link href="assets/themes/united.css" rel="stylesheet">
<body role="document">
<!-- Fixed navbar -->
<nav class="navbar navbar-inverse navbar-fixed-top">
<div class="container">
<div class="navbar-header">
<button type="button" class="navbar-toggle collapsed" data-toggle="collapse" data-target="#navbar" aria-expanded="false" aria-controls="navbar">
<span class="sr-only">Toggle navigation</span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
</button>
<a href="#"><img src="newlogo2.png" class="img-responsive" alt="Picture not loaded" ></a>
</div>
<div id="navbar" class="navbar-collapse collapse"style="padding-top: 0px;">
<ul class=" navbar-right list-inline"style="padding-top: 8px;">
<li class="dropdown">
<a href="" class="btn btn-default" class="dropdown-toggle" data-toggle="dropdown" role="button" aria-haspopup="true" aria-expanded="false">Sign Up <span class="caret"></span></a>
<ul class="dropdown-menu">
<li><a href="User sign up.html">User Sign up</a></li>
<li role="separator" class="divider"></li>
<li><a href="Doctor Sign up.html">Doctor Sign up</a></li>
</li>
</ul>
<li><a href="login pannel.html" class="btn btn-default">Log In</a></li>
</ul>
<ul class="nav navbar-nav ">
<li><a href="index.html">Home</a></li>
<li><a href="About us.html">About us</a></li>
<li><a href="#contact">Contact</a></li>
<li class="dropdown">
<a href="#" class="dropdown-toggle" data-toggle="dropdown" role="button" aria-haspopup="true" aria-expanded="false">Dropdown <span class="caret"></span></a>
<ul class="dropdown-menu">
<li><a href="#">Action</a></li>
<li><a href="#">Another action</a></li>
<li><a href="#">Something else here</a></li>
<li role="separator" class="divider"></li>
<li class="dropdown-header">Nav header</li>
<li><a href="#">Separated link</a></li>
<li><a href="#">One more separated link</a></li>
</ul>
</li>
</ul>
</div><!--/.nav-collapse -->
</div>
</nav>
</head>
<STYLE TYPE="text/css">
.jumbotron,
.page {
padding-top: 140px;
padding-bottom: 140px;
margin-bottom: 0px;
}
</STYLE>
<div class="text-center">
<div class="jumbotron">
<h1>User Sign up</h1>
</div>
</div>
<section>
<div class="container">
<h2>Personal Details</h2>
</div>
<form action="" class="form-inline">
<div class="well text-center">
<div>
<div class="form-group"style="text-indent:10px;">
<label for="Firstname">First Name</label>
<input type="text" class="form-control" id="fname" placeholder="Your First name" required>
</div>
<div class="form-group"style="text-indent:50px;">
<label for="Lastname">Last Name</label>
<input type="text" class="form-control" id="lname" placeholder="Enter your Last Name" required>
</div>
</div>
</div>
<div class= "well text-center">
<div class="form-group" style="text-indent:5px;">
<label for="Fathername">Father Name</label>
<input type="text" class="form-control" id="Fname" placeholder="Enter Your Father name" required>
</div>
<div class="form-group"style="text-indent:50px;">
<label for="password">Password</label>
<input type="password" class="form-control" id="password" placeholder="Enter your Password" required>
</div>
</div>
<div class="well text-center">
<div>
<div class="form-group" style="text-indent:30px;">
<label for="eCNIC">CNIC</label>
<input type="number" class="form-control" id="eCNIC" placeholder="Your CNIC" required>
</div>
<div class="form-group"style="text-indent:20px;">
<label for="Lastname">Confirm Password</label>
<input type="password" class="form-control" id="cpassword" placeholder="Confirm your Password" required>
</div>
</div>
</div>
<div class="well text-center">
<div>
<div class="form-group"style="text-indent:10px;">
<label for="Cno">Contact no</label>
<input type="number" class="form-control" id="Contactno" placeholder="Enter Your Contact no" required>
</div>
<div class="form-group"style="text-indent:60px;">
<label for="email">Email</label>
<input type="text" class="form-control" id="email" placeholder="Enter your Email">
</div>
</div>
</div>
<div class="well text-center">
<div>
<div class="form-group"style="text-indent:20px;">
<label for="address">Address</label>
<input type="text" class="form-control" id="address" placeholder="Enter Your address" required>
</div>
<div class="form-group"style="text-indent:50px;">
<label for="allergies">Allergies</label>
<input type="text" class="form-control" id="allergy" placeholder="Enter your Allergies">
</div>
</div>
</div>
<div class="container">
<h2>Emergency Contact information</h2>
</div>
<div class="well text-center">
<div>
<div class="form-group"style="text-indent:10px;">
<label for="contactname">Contact Name</label>
<input type="text" class="form-control" id="cname" placeholder="Your Contact name">
</div>
<div class="form-group"style="text-indent:50px;">
<label for="relationtop">Relation To Patient</label>
<input type="text" class="form-control" id="relation" placeholder="Enter Relationship">
</div>
</div>
</div>
<div class= "well text-center">
<div class="form-group" style="text-indent:3px;">
<label for="address">Address/city/zip</label>
<input type="text" class="form-control" id="address" placeholder="Enter address of relative">
</div>
<div class="form-group"style="text-indent:70px;">
<label for="hphone">Home Phone</label>
<input type="text" class="form-control" id="homeph" placeholder="Enter home phone num">
</div>
</div>
<div class="well text-center">
<div>
<div class="form-group" style="text-indent:20px;">
<label for="cphone">Cell Phone</label>
<input type="number" class="form-control" id="cellph" placeholder="Enter Cell Phone num">
</div>
<div class="form-group"style="text-indent:75px;">
<label for="wphone">Work Phone</label>
<input type="nember" class="form-control" id="workph" placeholder="Enetr work Phone num">
</div>
</div>
</div>
<div class="container">
<h2>Social History</h2>
</div>
<div class="well text-center">
<div>
<div class="form-group"style="text-indent:10px;">
<label for="cigarrete">Have you ever been a cigarrette smoker? </label>
<select class="form-control" id="cgsmoker"><div class="clear"></div>
<option>YES</option>
<option>NO</option>
</select>
</div>
<div class="form-group"style="text-indent:50px;">
<label for="relationtop">Have you ever smoked a cigar or pipe? </label>
<select class="form-control" id="cigarpipe"><div class="clear"></div>
<option>YES</option>
<option>NO</option>
</select>
</div>
</div>
</div>
<div class= "well text-center">
<div class="form-group" style="text-indent:75px;">
<label for="address">Do you drink alcohol? </label>
<select class="form-control" id="cgsmoker"><div class="clear"></div>
<option>YES</option>
<option>NO</option>
</select>
</div>
<div class="form-group"style="text-indent:75px;">
<label for="hphone">Do you use recreational drugs? </label>
<select class="form-control" id="recdrugs">
<option>YES</option>
<option>NO</option>
</select>
</div>
</div>
<div class="container">
<h2>Medications</h2>
</div>
<div class="well text-left">
<div class="multi-field-wrapper">
<div class="multi-fields">
<div class="multi-field col-sm-12">
<div class="form-group col-sm-4">
<label>Medicine Name</label>
<input type="text" class="form-control" name="medname[]"placeholder="Your Medicine Name">
</div>
<div class="form-group col-sm-4">
<label>Frequency taken</label>
<input type="text" class="form-control" name="frequency[]"placeholder="Enter miligrams of medicine">
</div>
<div class="form-group col-sm-3">
<label>Doses</label>
<select class="form-control" name="doses[]">
<option>Once</option>
<option>Twice</option>
<option>Thrice</option>
</select>
</div>
<button type="button" class="remove-field col-sm-0 btn btn-default" style="margin-top:5px;">
<span class="glyphicon glyphicon glyphicon-remove"></span></button>
</div>
</div>
<div class="text-center">
<button type="button" class="add-field btn btn-default">Add more medicine details</button>
</div>
</div>
</div>
<br>
<div class= "well text-center">
<div class="form-group">
<label for="medallergy">Medicine & Allergic reactions</label>
<input type="text" class="form-control" id="medicineallergy" placeholder="Enter medicine allergic reactions">
</div>
</div>
<hr>
<div class="container text-center">
<button type="submit" class="btn btn-lg btn-info">Submit</button>
</div>
</form>
</section>
<hr>
<footer>
<hr>
<div class=" text-center">
<h4>Enter your name and email</h4>
<form action="" class="form-inline">
<div class="form-group">
<label for="subscription">Subscribe</label>
<input type="text" class="form-control" id="subscription" placeholder="Your name">
</div>
<div class="form-group">
<label for="email">Email address</label>
<input type="text" class="form-control" id="email" placeholder="Enter your Email">
</div>
<button type="submit" class="btn btn-default">Subscribe</button>
</form>
<hr>
<div class="btn-group">
<a class="btn btn-md btn-info" href="http://www.twitter.com/">Twitter</a>
<a class="btn btn-md btn-info" href="http://www.facebook.com/">Facebook</a>
<a class="btn btn-md btn-info" href="http://www.youtube.com/">YouTube</a>
</div>
<hr>
<span class="label label-info">© Copyright Muhammad Bilal, Muhammad Irfan, Zar Mashal @ 2015</span>
</div><!-- end Container-->
</footer>
<script type="text/javascript">
$('.multi-field-wrapper').each(function() {
var $wrapper = $('.multi-fields', this);
$(".add-field", $(this)).click(function(e) {
$('.multi-field:first-child', $wrapper).clone(true).appendTo($wrapper).find('input').val('').focus();
});
$('.multi-field .remove-field', $wrapper).click(function() {
if ($('.multi-field', $wrapper).length > 1)
$(this).parent('.multi-field').remove();
});
});
</script>
<!-- jQuery (necessary for Bootstrap's JavaScript plugins) -->
<script src="assets/js/jquery.min.js"></script>
<!-- Include all compiled plugins (below), or include individual files as needed -->
<script src="assets/js/bootstrap.min.js"></script>
<!-- Start JS Config (This is where you configure the Bootstrap JS options) -->
<!-- End JS Config -->
</body>
</html>