<!doctype html> <html lang="en"> <head> <link rel="icon" href="../dist/img/hims.png"> <!-- Required meta tags --> <meta charset="utf-8"> <meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no"> <link rel="stylesheet" href="../assets/vendor/bootstrap/css/bootstrap.min.css"> <link href="../assets/vendor/fonts/circular-std/style.css" rel="stylesheet"> <link rel="stylesheet" href="../assets/libs/css/style.css"> <link rel="stylesheet" href="../assets/vendor/fonts/fontawesome/css/fontawesome-all.css"> <style> .form-group label{ color: #3d405c!important; } </style> <title>HIMS</title> </head> <body> <!-- ============================================================== --> <!-- main wrapper --> <!-- ============================================================== --> <div class="dashboard-main-wrapper"> <!-- ============================================================== --> <!-- navbar --> <!-- ============================================================== --> <?php include $_SERVER['DOCUMENT_ROOT'].'/hims/include/nav.php'; ?> <!-- ============================================================== --> <!-- end navbar --> <!-- ============================================================== --> <!-- ============================================================== --> <!-- left sidebar --> <!-- ============================================================== --> <?php include $_SERVER['DOCUMENT_ROOT'].'/hims/include/sidebar.php'; ?> <!-- ============================================================== --> <!-- end left sidebar --> <!-- ============================================================== --> <!-- ============================================================== --> <!-- wrapper --> <!-- ============================================================== --> <div class="dashboard-wrapper"> <div class="container-fluid dashboard-content"> <!-- ============================================================== --> <!-- pageheader --> <!-- ============================================================== --> <div class="row"> <div class="col-xl-12 col-lg-12 col-md-12 col-sm-12 col-12"> <div class="page-header"> <h2 class="pageheader-title">Registration Form </h2> <div class="page-breadcrumb"> <nav aria-label="breadcrumb"> <ol class="breadcrumb"> <li class="breadcrumb-item"><a href="#" class="breadcrumb-link">Dashboard</a></li> <li class="breadcrumb-item active" aria-current="page">Registration Form</li> </ol> </nav> </div> </div> </div> </div> <!-- ============================================================== --> <!-- end pageheader --> <!-- ============================================================== --> <div class=""> <div class="container-fluid dashboard-content"> <div class="row"> <div class="col-xl-10"> <div class="row"> <!-- ============================================================== --> <!-- basic form --> <!-- ============================================================== --> <div class="col-xl-12 col-lg-12 col-md-12 col-sm-12 col-12"> <?php include $_SERVER['DOCUMENT_ROOT'].'/hims/include/messages.php'; ?> <div class="card"> <h5 class="card-header">Patient Form</h5> <div class="card-body"> <form role="form" action="<?php echo WEB_ROOT; ?>views/process.php?cmd=register" id="form" data-parsley-validate="" method="post" class="needs-validation" novalidate> <input id="admitstat" type="text" name="status" required="" data-parsley-type="" placeholder="" class="form-control" value="REGISTERED" hidden> <div class="form-group row"> <label for="inputWebSite" class="col-3 col-lg-2 col-form-label text-left">IC Num</label> <div class="col-9 col-lg-10"> <input id="inputWebSite" type="" name="icnum" required="" data-parsley-type="number" placeholder="IC Num" class="form-control" required> </div> </div> <div class="form-group row"> <label for="inputWebSite" class="col-3 col-lg-2 col-form-label text-left">Name</label> <div class="col-9 col-lg-10"> <input name="name" id="inputWebSite" type="text" required="" data-parsley-type="" placeholder="Name" class="form-control"> </div> </div> <div class="form-group row"> <label for="exampleFormControlTextarea1" class="col-3 col-lg-2 col-form-label text-left">Address</label> <div class="col-9 col-lg-10"> <textarea name="address" class="form-control" id="exampleFormControlTextarea1" rows="3" placeholder="Address" required=""></textarea> </div> </div> <div class="form-group row"> <label for="input-select" class="col-3 col-lg-2 col-form-label text-left">Gender</label> <div class="col-9 col-lg-10"> <select class="form-control" name="gender" id="input-select" required=""> <option value="" disabled selected>Choose Gender</option> <option value="MALE">MALE</option> <option value="FEMALE">FEMALE</option> </select> </div> </div> <div class="form-group row"> <label for="input-select" class="col-3 col-lg-2 col-form-label text-left">Race</label> <div class="col-9 col-lg-10"> <select name="race" class="form-control" id="input-select" required=""> <option value="" disabled selected>Choose Race</option> <option value="MELAYU">MELAYU</option> <option value="CINA">CINA</option> <option value="IBAN">IBAN</option> <option value="BIDAYUH">BIDAYUH</option> <option value="KADAZAN">KADAZAN</option> <option value="MILANAU">MILANAU</option> <option value="PRIBUMI">PRIBUMI</option> <option value="LAIN-LAIN">LAIN-LAIN</option> </select> </div> </div> <div class="form-group row"> <label for="input-select" class="col-3 col-lg-2 col-form-label text-left">Nationality</label> <div class="col-9 col-lg-10"> <select name="nationality" class="form-control" id="input-select" required=""> <option value="" disabled selected>Choose Nationality</option> <option value="KELANTAN">KELANTAN</option> <option value="KEDAH">KEDAH</option> <option value="KUALA LUMPUR">KUALA LUMPUR</option> <option value="TERENGGANU">TERENGGANU</option> <option value="MELAKA">MELAKA</option> <option value="NEGERI SEMBILAN">NEGERI SEMBILAN</option> <option value="PAHANG">PAHANG</option> <option value="PENANG">PENANG</option> <option value="PERAK">PERAK</option> <option value="PERLIS">PERLIS</option> <option value="SABAH">SABAH</option> <option value="SARAWAK">SARAWAK</option> <option value="SELANGOR">SELANGOR</option> <option value="JOHOR">JOHOR</option> </select> </div> </div> <div class="form-group row"> <label for="inputWebSite" class="col-3 col-lg-2 col-form-label text-left">Birthdate</label> <div class="col-9 col-lg-10"> <input name="birthdate" id="inputWebSite" type="date" required="" data-parsley-type="date" placeholder="Birthdate" class="form-control" format="dd/mm/yyyy"> </div> </div> <div class="form-group row"> <label for="inputWebSite" class="col-3 col-lg-2 col-form-label text-left">Telephone</label> <div class="col-9 col-lg-10"> <input name="telephone" id="inputWebSite" required="" data-parsley-type="number" placeholder="Phone Number" class="form-control"> </div> </div> <div class="form-group row"> <label for="input-select" class="col-3 col-lg-2 col-form-label text-left">Religion</label> <div class="col-9 col-lg-10"> <select name="religion" class="form-control" id="input-select" required=""> <option value="" disabled selected>Choose Religion</option> <option value="ISLAM">ISLAM</option> <option value="BUDDHA">BUDDHA</option> <option value="HINDU">HINDU</option> <option value="KRISTIAN">KRISTIAN</option> <option value="OTHERS">OTHERS</option> <option value="NIL">NIL</option> </select> </div> </div> <div class="form-group row"> <label for="input-select" class="col-3 col-lg-2 col-form-label text-left">Marrital</label> <div class="col-9 col-lg-10"> <select name="marrital" class="form-control" id="input-select" required=""> <option value="" disabled selected>Choose Marrital Status</option> <option value="MARRIED">MARRIED</option> <option value="SINGLE">SINGLE</option> </select> </div> </div> <br><br><br> <div class="form-group row"> <h5 class="card-header">Patient Heir(Waris) Form</h5> <br> </div> <div class="form-group row"> <label for="inputEmail2" class="col-3 col-lg-2 col-form-label text-left">Name</label> <div class="col-9 col-lg-10"> <input name="w_name" id="inputEmail2" type="" required="" data-parsley-type="" placeholder="Name" class="form-control"> </div> </div> <div class="form-group row"> <label for="inputEmail2" class="col-3 col-lg-2 col-form-label text-left ">Relation</label> <div class="col-9 col-lg-10"> <input name="relation" id="inputEmail2" type="" required="" data-parsley-type="" placeholder="Relation" class="form-control"> </div> </div> <div class="form-group row"> <label for="inputWebSite" class="col-3 col-lg-2 col-form-label text-left">Telephone</label> <div class="col-9 col-lg-10"> <input name="w_telephone" id="inputWebSite" type="" required="" data-parsley-type="" placeholder="Phone Number" class="form-control"> </div> </div> <div class="form-group row"> <label for="exampleFormControlTextarea1" class="col-3 col-lg-2 col-form-label text-left">Address</label> <div class="col-9 col-lg-10"> <textarea name="w_address" class="form-control" id="exampleFormControlTextarea1" rows="3" placeholder="Address" required=""></textarea> </div> </div> <div class="row pt-2 pt-sm-5 mt-1"> <div class="col-sm-6 pb-2 pb-sm-4 pb-lg-0 pr-0"> </div> <div class="col-sm-6 pl-0"> <p class="text-right"> <button type="submit" class="btn btn-space btn-primary">Submit</button> <button type="reset" class="btn btn-space btn-secondary">Clear</button> </p> </div> </div> </form> </div> </div> </div> <!-- ============================================================== --> <!-- end basic form --> <!-- ============================================================== --> </div> </div> </div> </div> </div> </div> <!-- ============================================================== --> <!-- footer --> <!-- ============================================================== --> <div class="footer"> <div class="container-fluid"> <div class="row"> <div class="col-xl-6 col-lg-6 col-md-12 col-sm-12 col-12"> Copyright © 2018 Concept. All rights reserved. Dashboard by <a href="https://colorlib.com/wp/">Colorlib</a>. </div> <div class="col-xl-6 col-lg-6 col-md-12 col-sm-12 col-12"> <div class="text-md-right footer-links d-none d-sm-block"> <a href="javascript: void(0);">About</a> <a href="javascript: void(0);">Support</a> <a href="javascript: void(0);">Contact Us</a> </div> </div> </div> </div> </div> <!-- ============================================================== --> <!-- end footer --> <!-- ============================================================== --> </div> </div> <!-- ============================================================== --> <!-- end main wrapper --> <!-- ============================================================== --> <!-- Optional JavaScript --> <script src="../assets/vendor/jquery/jquery-3.3.1.min.js"></script> <script src="../assets/vendor/bootstrap/js/bootstrap.bundle.js"></script> <script src="../assets/vendor/slimscroll/jquery.slimscroll.js"></script> <script src="../assets/vendor/parsley/parsley.js"></script> <script src="../assets/libs/js/main-js.js"></script> <script> $('#form').parsley(); </script> <script> // Example starter JavaScript for disabling form submissions if there are invalid fields (function() { 'use strict'; window.addEventListener('load', function() { // Fetch all the forms we want to apply custom Bootstrap validation styles to var forms = document.getElementsByClassName('needs-validation'); // Loop over them and prevent submission var validation = Array.prototype.filter.call(forms, function(form) { form.addEventListener('submit', function(event) { if (form.checkValidity() === false) { event.preventDefault(); event.stopPropagation(); } form.classList.add('was-validated'); }, false); }); }, false); })(); </script> <script> $(document).ready(function() { $(window).keydown(function(event){ if(event.keyCode == 13) { event.preventDefault(); return false; } }); }); </script> </body> </html>