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patientregistration.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title>DENEX | Patient Registration</title>
<meta
name="viewport"
content="width=device-width,initial-scale=1,shrink-to-fit=no"
/>
<meta name="title" content="Tracker" />
<link
rel="stylesheet"
href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css"
integrity="sha384-B0vP5xmATw1+K9KRQjQERJvTumQW0nPEzvF6L/Z6nronJ3oUOFUFpCjEUQouq2+l"
crossorigin="anonymous"
/>
<link rel="shortcut icon" href="images/favicon.ico" type="image/x-icon" />
</head>
<body style="background-color: #122f37">
<main>
<div class="section section-lg pt-5 bg-soft">
<div class="container">
<div class="row justify-content-center">
<div class="col-12">
<!-- <div id="pageLoader" class="container text-center d-flex align-items-center justify-content-center w-100" style="height: 100vh;">
<div class="spinner-border text-dark" style="width: 3rem; height: 3rem;" role="status">
<span class="visually-hidden">Loading...</span>
</div>
</div> -->
<div class="" id="pageContent">
<div
class="
d-flex
flex-column flex-lg-row
align-items-center
justify-content-between
mb-4
"
>
<h4
class="mb-3 mb-lg-0 text-white font-weight-bold"
style="font-weight: 900"
>
DENEX
</h4>
<div>
<button class="btn btn-outline-light" onclick="logout()">
Logout<span class="fas fa-power-off ml-1"></span>
</button>
</div>
</div>
<div class="card border-light p-4 p-md-5">
<form
action="#"
id="completeProfileForm"
class="needs-validation"
novalidate
>
<div class="row">
<div class="col-12 mb-3">
<h5 class="font-weight-bold">
Please fill out the form below to complete your
registration process.
</h5>
</div>
<div class="col-12">
<h4 class="font-weight-bold">Personal Information</h4>
</div>
<!-- Personal Details -->
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">First Name</h6>
<input
type="text"
name="nameForm-1"
id="firstName"
class="form-control mt-2 w-lg-75 charOnly"
placeholder="First Name"
required
/>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">Last Name</h6>
<input
type="text"
name="nameForm-1"
id="lastName"
class="form-control mt-2 w-lg-75 charOnly"
placeholder="Last Name"
required
/>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">Address</h6>
<input
type="text"
name="subjectForm-1"
id="address"
class="form-control mt-2 w-lg-75"
placeholder="Address"
minlength="6"
maxlength="12"
required
/>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">Phone Number</h6>
<input
type="text"
name="subjectForm-1"
id="phone"
class="form-control mt-2 w-lg-75"
placeholder="Phone"
minlength="6"
maxlength="12"
required
/>
</div>
<div class="col-12 my-2">
<h6 class="mb-0">Concern</h6>
<textarea
class="form-control w-lg-75 mt-3"
id="concern"
rows="3"
placeholder="If Yes, elaborate."
required
></textarea>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">X-Ray</h6>
<input
type="file"
name="fileForm-1"
id="x-ray"
class="form-control-file mt-2 w-lg-75"
placeholder="X-Ray"
required
/>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">Design</h6>
<input
type="file"
name="fileForm-2"
id="design"
class="form-control-file mt-2 w-lg-75"
placeholder="Design"
required
/>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">Duration of Treatment</h6>
<input
type="number"
name="durationForm-1"
id="duration"
class="form-control mt-2 w-lg-75"
placeholder="2 weeks"
required
/>
</div>
<div class="col-12 col-md-6 my-2">
<h6 class="mb-0">Start Date of Treatment</h6>
<input
type="date"
name="dateForm-1"
id="startdate"
class="form-control mt-2 w-lg-75"
placeholder=""
required
/>
</div>
<div class="col-12 my-2">
<h6 class="mb-0">Doctor In-Charge</h6>
<input
type="text"
name="nameForm-3"
id="doctor"
class="form-control mt-2 w-lg-75 charOnly"
placeholder="Doctor Name"
required
/>
</div>
<!-- Personal Details End -->
<div class="col-12 mt-4">
<span
id="formMessage"
class="text-danger font-weight-bold d-none"
>
Oops, there was a problem updating your profile.
Please try again.
</span>
</div>
<div class="col-12 mt-2">
<button
id="formButton"
class="btn btn-dark px-4"
type="submit"
>
Finish Registration
</button>
<button
id="formButton"
class="btn btn-dark px-4"
type="submit"
>
Delete
</button>
<span
id="formSubmitLoader"
class="spinner-border text-dark ml-2 d-none"
role="status"
>
<span class="visually-hidden">Loading...</span>
</span>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</div>
</main>
<script
src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.6.0/jquery.js"
integrity="sha512-n/4gHW3atM3QqRcbCn6ewmpxcLAHGaDjpEBu4xZd47N0W2oQ+6q7oc3PXstrJYXcbNU1OHdQ1T7pAP+gi5Yu8g=="
crossorigin="anonymous"
referrerpolicy="no-referrer"
></script>
<script
src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.bundle.min.js"
integrity="sha384-Piv4xVNRyMGpqkS2by6br4gNJ7DXjqk09RmUpJ8jgGtD7zP9yug3goQfGII0yAns"
crossorigin="anonymous"
></script>
<script src="js/config.js"></script>
<script src="js/logout.js"></script>
</body>
</html>