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signup.html
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signup.html
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<!DOCTYPE html>
<html >
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1, minimum-scale=1">
<link rel="shortcut icon" href="assets/images/favicon-1.svg" type="image/x-icon">
<meta name="description" content="">
<title>Public Sign Up - Curec</title>
<link rel="stylesheet" href="assets/Material-Design-Icons/css/material.css">
<link rel="stylesheet" href="assets/FontAwesome/css/font-awesome.css">
<link rel="stylesheet" href="assets/web/assets/mobirise-icons2/mobirise2.css">
<link rel="stylesheet" href="assets/tether/tether.min.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap.min.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap-grid.min.css">
<link rel="stylesheet" href="assets/bootstrap/css/bootstrap-reboot.min.css">
<link rel="stylesheet" href="assets/dropdown/css/style.css">
<link rel="stylesheet" href="assets/formstyler/jquery.formstyler.css">
<link rel="stylesheet" href="assets/formstyler/jquery.formstyler.theme.css">
<link rel="stylesheet" href="assets/datepicker/jquery.datetimepicker.min.css">
<link rel="stylesheet" href="assets/socicon/css/styles.css">
<link rel="stylesheet" href="assets/theme/css/style.css">
<link rel="preload" href="https://fonts.googleapis.com/css?family=Muli:200,200i,300,300i,400,400i,500,500i,600,600i,700,700i,800,800i,900,900i&display=swap" as="style" onload="this.onload=null;this.rel='stylesheet'">
<noscript><link rel="stylesheet" href="https://fonts.googleapis.com/css?family=Muli:200,200i,300,300i,400,400i,500,500i,600,600i,700,700i,800,800i,900,900i&display=swap"></noscript>
<link rel="preload" as="style" href="assets/mobirise/css/mbr-additional.css"><link rel="stylesheet" href="assets/mobirise/css/mbr-additional.css" type="text/css">
<script src="./access/doctor/system/js/healthAPI.js"></script>
<meta name="theme-color" content="#4f87fb">
<link rel="manifest" href="manifest.json">
<script src="sw-connect.js"></script>
<meta name="apple-mobile-web-app-capable" content="yes">
<link rel="apple-touch-startup-image" media="(device-width: 320px) and (device-height: 568px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-640x1136.png">
<link rel="apple-touch-startup-image" media="(device-width: 375px) and (device-height: 667px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-750x1334.png">
<link rel="apple-touch-startup-image" media="(device-width: 414px) and (device-height: 736px) and (-webkit-device-pixel-ratio: 3) and (orientation: portrait)" href="assets/images/apple-launch-1242x2208.png">
<link rel="apple-touch-startup-image" media="(device-width: 375px) and (device-height: 812px) and (-webkit-device-pixel-ratio: 3) and (orientation: portrait)" href="assets/images/apple-launch-1125x2436.png">
<link rel="apple-touch-startup-image" media="(device-width: 768px) and (device-height: 1024px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-1536x2048.png">
<link rel="apple-touch-startup-image" media="(device-width: 834px) and (device-height: 1112px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-1668x2224.png">
<link rel="apple-touch-startup-image" media="(device-width: 1024px) and (device-height: 1366px) and (-webkit-device-pixel-ratio: 2) and (orientation: portrait)" href="assets/images/apple-launch-2048x2732.png">
<meta name="apple-mobile-web-app-status-bar-style" content="default">
<meta name="apple-mobile-web-app-title" content="CuRec">
<link rel="apple-touch-icon" href="apple-touch-icon.png">
</head>
<body>
<section class="menu01 cid-sH161TwuG3" once="menu" id="menu1-t">
<nav class="navbar navbar-dropdown beta-menu align-items-center navbar-fixed-top navbar-toggleable-sm bg-color transparent">
<div class="menu-bottom order-0 order-lg-1">
<div class="menu-logo">
<div class="navbar-brand">
<span class="navbar-logo">
<a href="index.html">
<img src="assets/images/logo-121x57.png" alt="CuRec" style="height: 3.8rem;">
</a>
</span>
</div>
<button class="navbar-toggler" type="button" data-toggle="collapse" data-target="#navbarSupportedContent, #topLine" aria-controls="navbarSupportedContent" aria-expanded="false" aria-label="Toggle navigation">
<div class="hamburger">
<span></span>
<span></span>
<span></span>
<span></span>
</div>
</button>
</div>
<div class="collapse navbar-collapse" id="navbarSupportedContent">
<ul class="navbar-nav nav-dropdown js-float-line" data-app-modern-menu="true"><li class="nav-item">
<a class="nav-link link mbr-black text-secondary text-primary display-4" href="index.html">
Home
</a>
</li>
<li class="nav-item">
<a class="nav-link link mbr-black text-secondary text-primary display-4" href="index.html#info1-1u">
Contact Us
</a>
</li></ul>
<div class="navbar-buttons mbr-section-btn"><a class="btn btn-md btn-primary-outline display-4" href="signin.html">SIGN IN</a></div>
</div>
</div>
</nav>
</section>
<section class="header1 cid-sHb4yCr9b6" id="header10-1o">
<svg class="svg1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" width="1380px" height="810px" viewBox="0 0 1380 810" preserveAspectRatio="xMidYMid meet">
<rect id="svgEditorBackground" x="0" y="0" width="1380" height="810" style="fill: none; stroke: none;"></rect>
<circle id="e1_circle" cx="309" cy="433" style="fill:aqua;stroke:black;stroke-width:0px;" r="149.486"></circle>
<circle id="e3_circle" cx="679" cy="707" style="fill: aqua; stroke-width: 0px;stroke:black;" r="516.715">
</circle>
<circle id="e4_circle" cx="759" cy="261" style="fill:aqua;stroke:black;stroke-width:0px;" r="132.2459829258">
</circle>
<circle id="e5_circle" cx="1054" cy="462" style="fill:aqua;stroke:black;stroke-width:0px;" r="139.413"></circle>
<circle id="e6_circle" cx="691" cy="692" style="fill:khaki;stroke:black;stroke-width:0px;" r="367.214"></circle>
</svg>
<div class="round round1 rev"></div>
<div class="round round2 rev"></div>
<div class="round round3"></div>
<div class="round round4 rev"></div>
<div class="round round5"></div>
<div class="round round6 rev"></div>
<div class="round round7"></div>
<div class="round round8 rev"></div>
<div class="round round9 rev"></div>
<div class="round round10"></div>
<div class="round round11"></div>
<div class="container">
<div class="row justify-content-md-center">
<div class="col-md-10 align-center">
</div>
</div>
</div>
</section>
<section class="firmm4_form3 form3 cid-sH161WPvsi" id="form3-w">
<div class="container">
<div class="signup_wrap">
<div class="row justify-content-center">
<div class="col-lg-5 col-md-5 col-12">
<div class="title_block">
<h3 class="mbr-section-title mbr-fonts-style display-7">
<strong>Already have an account?</strong>
</h3>
<h4 class="mbr-section-subtitle mbr-fonts-style mbr-light display-7">Sign in now and keep yourself away from COVID-19</h4>
<div class="card_body">
<ul class="list mbr-fonts-style display-4">
<li class="mbr-text item-wrap"><span class="mobi-mbri mobi-mbri-success mbr-iconfont"></span>Lorem ipsum inventore</li>
<li class="mbr-text item-wrap"><span class="mobi-mbri mobi-mbri-success mbr-iconfont"></span>Dolor sit amet</li>
<li class="mbr-text item-wrap"><span class="mobi-mbri mobi-mbri-success mbr-iconfont"></span>Consectetur adipisicing elit</li>
</ul>
</div>
<div class="mbr-section-btn"><a class="btn btn-sm btn-primary display-4" href="signin.html">Sign In</a></div>
</div>
</div>
<div class="col-lg-7 col-md-7 col-12">
<div class="form_wrap">
<h3 class="form_title mbr-fonts-style display-5">
<strong>Sign Up</strong>
</h3>
<div class="mbr-form">
<!--Formbuilder Form-->
<form action="./access/dbClass.php" method="POST" class="mbr-form form-with-styler mx-auto">
<div class="">
<div hidden="hidden" data-form-alert-danger="" class="alert alert-danger col-12">Oops...! some problem!</div>
</div>
<div class="dragArea">
<div class="col-lg-12 col-md-12 col-sm-12 form-group" data-for="name">
<label for="name-form3-w" class="form-control-label mbr-fonts-style display-7">Name</label>
<input type="text" name="name" placeholder="Nimesh Ekanayake" data-form-field="name" required="required" class="form-control display-7" value="" id="name-form3-w">
</div>
<div class="col form-group" data-for="contactnumber">
<label for="contactnumber-form3-w" class="form-control-label mbr-fonts-style display-7">Contact Number</label>
<input type="text" name="contactnumber" placeholder="0712345678" data-form-field="contactnumber" required="required" class="form-control display-7" value="" id="contactnumber-form3-w">
</div>
<div data-for="bloodgroup" class="col form-group">
<label for="bloodgroup-form3-w" class="form-control-label mbr-fonts-style display-7">Blood Group</label>
<select name="bloodgroup" data-form-field="bloodgroup" class="form-control display-7" id="bloodgroup-form3-w">
<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 data-for="hometown" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="hometown-form3-w" class="form-control-label mbr-fonts-style display-7">Hometown</label>
<input type="text" name="hometown" placeholder="Colombo" data-form-field="hometown" class="form-control display-7" required="required" value="" id="hometown-form3-w">
</div>
<div data-for="mohoffice" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="mohoffice-form3-w" class="form-control-label mbr-fonts-style display-7">MOH Office</label>
<select name="mohoffice" data-form-field="mohoffice" class="form-control display-7" id="mohoffice-form3-w">
<option value="Colombo">Colombo</option>
<option value="Homagama">Homagama</option>
<option value="Negombo">Negombo</option>
</select>
</div>
<div data-for="nic" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="nic-form3-w" class="form-control-label mbr-fonts-style display-7">NIC Number</label>
<input type="text" name="nic" placeholder="922120700v" data-form-field="nic" required="required" class="form-control display-7" value="" id="nic-form3-w">
</div>
<div class="col-auto form-group" data-for="password">
<label for="password-form3-w" class="form-control-label mbr-fonts-style display-7">Password</label>
<input type="password" name="password" placeholder="**********" data-form-field="password" required="required" class="form-control display-7" value="" id="password-form3-w">
</div>
<div data-for="confpassword" class="col-lg-12 col-md-12 col-sm-12 form-group">
<label for="confpassword-form3-w" class="form-control-label mbr-fonts-style display-7">Confirm Password</label>
<input type="password" name="confpassword" placeholder="**********" data-form-field="confpassword" required="required" class="form-control display-7" value="" id="confpassword-form3-w">
</div>
<div class="col-auto col-lg-4 col-sm-6 mbr-section-btn align-center">
<button type="submit" class="btn btn-sm btn-primary display-4" name="signup">Sign Up</button>
</div>
</div>
</form><!--Formbuilder Form-->
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section class="footer1 audiom4_footer1 cid-sHiy402oi2 mbr-reveal" once="footers" id="footer1-1z">
<div class="container">
<div class="media-container-row align-center mbr-white">
<div class="row title-row">
<h1 class="mbr-section-title align-center mbr-bold pb-1 mbr-fonts-style display-5">
Curec</h1>
</div>
<div class="row social-row">
<div class="social-list align-right pb-2">
<div class="soc-item">
<a href="https://twitter.com/mobirise" target="_blank">
<span class="socicon-twitter socicon mbr-iconfont mbr-iconfont-social"></span>
</a>
</div><div class="soc-item">
<a href="https://www.facebook.com/pages/Mobirise/1616226671953247" target="_blank">
<span class="socicon-facebook socicon mbr-iconfont mbr-iconfont-social"></span>
</a>
</div><div class="soc-item">
<a href="https://www.youtube.com/c/mobirise" target="_blank">
<span class="socicon-youtube socicon mbr-iconfont mbr-iconfont-social"></span>
</a>
</div></div>
</div>
<div class="row row-links">
<ul class="foot-menu">
<li class="foot-menu-item mbr-fonts-style display-4">+9411 263 5268</li><li class="foot-menu-item mbr-fonts-style display-4">
info@curec.life
</li><li class="foot-menu-item mbr-fonts-style display-4">Ratmalana, Sri Lanka</li></ul>
</div>
<div class="row row-copirayt">
<p class="mbr-text mb-0 mbr-fonts-style mbr-white align-center display-4">
© Copyright 2021 <a href="https://www.kdu.ac.lk" class="text-primary">Kotelawala Defence Univerisity</a> - All Rights Reserved
</p>
</div>
</div>
</div>
</section>
<script src="assets/web/assets/jquery/jquery.min.js"></script>
<script src="assets/popper/popper.min.js"></script>
<script src="assets/tether/tether.min.js"></script>
<script src="assets/bootstrap/js/bootstrap.min.js"></script>
<script src="assets/smoothscroll/smooth-scroll.js"></script>
<script src="assets/dropdown/js/nav-dropdown.js"></script>
<script src="assets/dropdown/js/navbar-dropdown.js"></script>
<script src="assets/touchswipe/jquery.touch-swipe.min.js"></script>
<script src="assets/formstyler/jquery.formstyler.js"></script>
<script src="assets/formstyler/jquery.formstyler.min.js"></script>
<script src="assets/datepicker/jquery.datetimepicker.full.js"></script>
<script src="assets/theme/js/script.js"></script>
</body>
</html>