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form3register.php
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form3register.php
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<title>healthcare world</title>
<link rel="shortcut icon" href="heart-.ico"/>
<link rel="stylesheet" href="pagecss.css">
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/4.0.0-beta/css/bootstrap.min.css" integrity="sha384-/Y6pD6FV/Vv2HJnA6t+vslU6fwYXjCFtcEpHbNJ0lyAFsXTsjBbfaDjzALeQsN6M" crossorigin="anonymous">
</head>
<body style="border:0px;" >
<nav class="navbar navbar-expand-lg navbar-dark bg-dark">
<div class="go">
<a class="navbar-brand" href="after_login.php">home</a>
</div>
<button class="navbar-toggler" type="button" data-toggle="collapse" data-target="#navbarSupportedContent" aria-controls="navbarSupportedContent" aria-expanded="false" aria-label="Toggle navigation">
<span class="navbar-toggler-icon"></span>
</button>
<div class="collapse navbar-collapse" id="navbarSupportedContent">
<ul class="navbar-nav mr-auto">
<li class="nav-item active go">
<a class="nav-link" href="aboutus.htm">about us <span class="sr-only">(current)</span></a>
</li>
<li class="nav-item active go">
<a class="nav-link" href="team.htm">team</a>
</li>
<li class="nav-item active go">
<a class="nav-link" href="contact.php">conatct us</a>
</li>
<li class="nav-item active go">
<a class="nav-link" href="#">learn</a>
</li>
</ul>
<!-- <form class="form-inline my-2 my-lg-0">
<button class="btn btn-outline-danger my-2 my-sm-0 but do" data-toggle="modal" data-target="#modal" type="button">Signup</button>
<button class="btn btn-outline-success my-2 my-sm-0 do" type="button" data-toggle="modal" data-target="#mmodal" >Login</button>
</form> -->
</div>
</nav>
<h3 align="center" style="padding-top: 50px;margin-bottom: -40px;" >Please Register here</h3>
<div style="margin-top: 80px;margin-bottom: 10px; border:0px; border-color: white;" align="center">
<form name="signin" id="form2" class="animate" action="docinfo.php" method="post">
<input type="text" autofocus="autofocus" class="manage" style="padding-left:10px;" style="margin-top:20px; " placeholder="Name of the patient*" name="name" required>
<br><br>
<input type="number" class="manage" style="padding-left:10px;" max="90" placeholder="Age *" name="age" required>
<br><br>
<label style="margin-left: -410px;" class="text-muted">Sex</label><br>
<div style="margin-left: -20px;">
<input type="radio" name="gender" value="male" checked > Male
<input type="radio" name="gender" value="female"> Female
<input type="radio" name="gender" value="other"> Other
</div>
<br><br>
<input type="text" class="manage" style="padding-left:10px;" size="300" placeholder="address *" name="address" required><br><br>
<input type="number" maxlength="6" class="manage" style="padding-left:10px;" placeholder="pin" name="pin"><br><br>
<input type="email" class="manage" style="padding-left:10px;" placeholder="Enter Email*" name="email" required>
<br><br>
<div style="display:inline-block;">
<label class="text-muted" name="as" required style="margin-left:-10px ;padding-right: 7px;">+91</label>
<input type="number" maxlength="10" class="m" placeholder="contact number" name="number" required style="width:399px;padding-left:10px;">
</div>
<br><br>
<input type="text" class="manage" style="padding-left:10px;" placeholder="disease to be diagnosed" name="disease" required >
<br><br>
<div>
<!-- <input type="checkbox" list="" class="manage" style="padding-left:10px;" placeholder="doctor" name="rpas" required > -->
<!-- <input list="doctors" class="manage" style="padding-left:10px;" placeholder="doctor" required >
<datalist id="docs">
<option value="A">
<option value="B">
<option value="C">
<option value="D">
<option value="E">
</datalist>
-->
<div class="text-muted">
<select name="doctor" id="docs" class="manage" style="padding-left:10px;" required class="text-muted">
<option value="" >which doctor you would like to choose</option>
<option value="devi prasad shetty">devi prasad shetty</option>
<option value="naresh trehan">naresh trehan</option>
<option value="deepak chopra">deepak chopra</option>
<option value="aamod roa">aamod roa</option>
<option value="sanjay borude">sanjay borude</option>
<option value="ramneek mahajan">ramneek mahajan</option>
</select></div>
</div>
<br><br>
<input type="text" class="manage" style="padding-left:10px;" placeholder="allergic to any medicine" name="allergies" required>
<br><br>
<input type="text" class="manage" style="padding-left:10px;" placeholder="location" name="pas" required>
<br><br>
<br><br>
<label style="margin-left: -340px;" class="text-muted">date of birth</label><br>
<input id="dateofbirth" type="Date" class="manage" style="padding-left:10px;" placeholder="date of birth" name="dob" required>
<br><br>
<button type="submit" class="signupbtn btn-success round w-100" name="regbut" >Register</button>
</form>
</div>
<p style="font"></p>
<p style="background-color:#8e8585;color:black;margin-bottom: -20px;" align="center"><img src="copy.png" height="18px" width="18px" style="margin-right: 5px;"> jaypee institute of information technology</p>
<script src="https://code.jquery.com/jquery-3.2.1.slim.min.js" integrity="sha384-KJ3o2DKtIkvYIK3UENzmM7KCkRr/rE9/Qpg6aAZGJwFDMVNA/GpGFF93hXpG5KkN" crossorigin="anonymous"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.11.0/umd/popper.min.js" integrity="sha384-b/U6ypiBEHpOf/4+1nzFpr53nxSS+GLCkfwBdFNTxtclqqenISfwAzpKaMNFNmj4" crossorigin="anonymous"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/4.0.0-beta/js/bootstrap.min.js" integrity="sha384-h0AbiXch4ZDo7tp9hKZ4TsHbi047NrKGLO3SEJAg45jXxnGIfYzk4Si90RDIqNm1" crossorigin="anonymous"></script>
<script src="pagejs.js"></script>
</body>
</html>