/
hospital_registration.html
82 lines (70 loc) · 2.32 KB
/
hospital_registration.html
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
<!DOCTYPE html>
<html>
<head>
<meta charset="UTF-8">
<title>Healthcare</title>
<link rel="stylesheet" type="text/css" href="./css/bootstrap.min.css">
<link rel="stylesheet" type="text/css" href="./css/styles.css">
</head>
<body>
<div class="vertical-center">
<div class="container">
<div class="row">
<div class="col-md-8 col-md-offset-2 well">
<h1 class="text-center">Hospital Registration</h1>
<form action="hospital_reg.php" method = "POST">
<div class="form-group">
<label>Hospital Name</label>
<div class="input-group">
<span class="input-group-addon">
<i class="glyphicon glyphicon-user"> </i>
</span>
<input type="text" name="hospital_name" class="form-control" required>
</div>
</div>
<div class="form-group">
<label>Hospital ID</label>
<div class="input-group">
<span class="input-group-addon">
<i class="glyphicon glyphicon-user"> </i>
</span>
<input type="text" name="hospital_id" class="form-control" required>
</div>
</div>
<div class="form-group">
<label>Hospital location</label>
<div class="input-group">
<span class="input-group-addon">
<i class="glyphicon glyphicon-home"> </i>
</span>
<input type="text" name="location" class="form-control" required>
</div>
</div>
<div class="form-group">
<label>Password</label>
<div class="input-group">
<span class="input-group-addon">
<i class="glyphicon glyphicon-asterisk"></i>
</span>
<input type="password" name="password" class="form-control" required>
</div>
</div>
<div class="form-group">
<label> Retype password</label>
<div class="input-group">
<span class="input-group-addon">
<i class="glyphicon glyphicon-asterisk"></i>
</span>
<input type="password" name="repassword" class="form-control" required>
</div>
</div>
<div class="form-group">
<input type="submit" value="REGISTER" class="btn btn-primary btn-block">
</div>
</form>
</div>
</div>
</div>
</div>
</body>
</html>