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appointment.html
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appointment.html
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<html>
<head>
<title>Make An Appointment</title>
<link rel = "stylesheet" href = "css/appointment.css" />
<script language="Javascript" type="text/javascript">
function onlyAlphabets(e, t) {
try {
if (document.event) {
var charCode = document.event.keyCode;
}
else if (e) {
var charCode = e.which;
}
else { return true; }
if ((charCode > 64 && charCode < 91) || (charCode > 96 && charCode < 123))
return true;
else
return false;
}
catch (err) {
alert(err.Description);
}
}
function onlyNumbers(e, t) {
try {
if (document.event) {
var charCode = document.event.keyCode;
}
else if (e) {
var charCode = e.which;
}
else { return true; }
if ((charCode > 47 && charCode < 58) || (charCode == 45))
return true;
else
return false;
}
catch (err) {
alert(err.Description);
}
}
function onlyAlphanumeric(e, t) {
try {
if (document.event) {
var charCode = document.event.keyCode;
}
else if (e) {
var charCode = e.which;
}
else { return true; }
if ((charCode > 47 && charCode < 58) || (charCode > 64 && charCode < 91) || (charCode > 96 && charCode < 123) || (charCode == 32) || (charCode == 44) || (charCode == 46))
return true;
else
return false;
}
catch (err) {
alert(err.Description);
}
}
function setInsurance_num(){
var el = document.getElementById("insurance1");
if(el.checked)
document.getElementById("insurance_num").disabled = false;
else
document.getElementById("insurance_num").disabled = true;
var el = document.getElementById("insurance2");
if(el.checked)
document.getElementById("insurance_num").disabled = true;
else
document.getElementById("insurance_num").disabled = false;
}
</script>
</head>
<body>
<div id = "appointment1">
<header>
<img src = "img/logo.png" alt = "Logo" />
<h1>NMIT HOSPITALS</h1>
<h2>A One-Stop Solution To Keep You Healthy</h2>
</header>
</div>
<div id = "appointment2">
<br />
<form action = "appointmentprocessing.php" method = "post">
<h2>Patient Information:</h2>
<label for = "fname">Legal First Name:</label>
<input type = "text" id = "fname" name = "firstname" placeholder = "Your name...(Mandatory)" maxlength = "50" pattern = "/^[A-Za-z\s]*${,50}" required autocomplete = "off" onkeypress = "return onlyAlphabets(event,this);" />
<label for = "lname">Legal Last Name:</label>
<input type = "text" id = "lname" name = "lastname" placeholder = "Your last name...(Mandatory)" maxlength = "50" pattern = "[A-Za-z\s]*{,50}" required autocomplete = "off" onkeypress = "return onlyAlphabets(event,this);" />
<label for = "addr">Address:</label>
<input type = "text" id = "addr" name = "address" placeholder = "Your address...(Mandatory)" maxlength = "150" pattern = "[A-Za-z0-9\s]{,150}" required autocomplete = "off" onkeypress = "return onlyAlphanumeric(event,this);"/>
<label for = "city">City:</label>
<input type = "text" id = "city" name = "city" placeholder = "Your city...(Mandatory)" maxlength = "50" pattern = "[A-Za-z\s]{,50}" required autocomplete = "off" onkeypress = "return onlyAlphabets(event,this);"/>
<label for = "state">State OR Union Territory:</label>
<select class = "state" id = "state" name = "state" required>
<option value = "Andhra Pradesh">Andhra Pradesh</option>
<option value = "Arunachal Pradesh">Arunachal Pradesh</option>
<option value = "Assam">Assam</option>
<option value = "Bihar">Bihar</option>
<option value = "Chattisgarh">Chattisgarh</option>
<option value = "Goa">Goa</option>
<option value = "Gujarat">Gujarat</option>
<option value = "Haryana">Haryana</option>
<option value = "Himachal Pradesh">Himachal Pradesh</option>
<option value = "Jammu & Kashmir">Jammu & Kashmir</option>
<option value = "Jharkhand">Jharkhand</option>
<option value = "Karnataka" selected = "selected">Karnataka</option>
<option value = "Kerala">Kerala</option>
<option value = "Madhya Pradesh">Madhya Pradesh</option>
<option value = "Maharashtra">Maharashtra</option>
<option value = "Manipur">Manipur</option>
<option value = "Meghalaya">Meghalaya</option>
<option value = "Mizoram">Mizoram</option>
<option value = "Nagaland">Nagaland</option>
<option value = "Odisha">Odisha(Orissa)</option>
<option value = "Punjab">Punjab</option>
<option value = "Rajasthan">Rajasthan</option>
<option value = "Sikkim">Sikkim</option>
<option value = "Tamil Nadu">Tamil Nadu</option>
<option value = "Telangana">Telangana</option>
<option value = "Tripura">Tripura</option>
<option value = "Uttar Pradesh">Uttar Pradesh</option>
<option value = "Uttarkhand">Uttarakhand</option>
<option value = "West Bengal">West Bengal</option>
<option value = "Andaman and Nicobar Islands">Andaman and Nicobar Islands</option>
<option value = "Chandigarh">Chandigarh</option>
<option value = "Dadra and Nagar Haveli">Dadra and Nagar Haveli</option>
<option value = "Daman and Diu">Daman and Diu</option>
<option value = "Lakshadweep">Lakshadweep</option>
<option value = "Delhi- National Capital Territory">Delhi-National Capital Territory</option>
<option value = "Puducherry">Puducherry(Pondicherry)</option>
</select>
<label for = "pincode">PIN:</label>
<input type = "text" id = "pincode" name = "pincode" placeholder = "Your pincode...(Mandatory)" maxlength = "6" pattern = "[0-9]{6}" required autocomplete = "off" onkeypress = "return onlyNumbers(event,this);" />
<label for = "primaryphone">Mobile Number:</label>
<input type = "text" id = "primaryphone" name = "primaryphone" placeholder = "Your number...(Mandatory)" maxlength = "10" pattern = "[0-9]{10}" required autocomplete = "off" onkeypress = "return onlyNumbers(event,this);" /><br />
<br />
<label for = "email">E-mail ID:</label>
<input type = "email" id = "email" name = "email" placeholder = "Your e-mail address..." maxlength = "60" autocomplete = "off" />
<br />
<label>Gender:</label>
<input type = "radio" class = "gender" name = "gender" value = "Male" checked = "checked">Male</input>
<input type = "radio" class = "gender" name = "gender" value = "Female">Female</input>
<input type = "radio" class = "gender" name = "gender" value = "Other">Other</input><br />
<br />
<label>Birth Date:</label>
<select id = "dob" name = "day">
<option value = "01">01</option>
<option value = "02">02</option>
<option value = "03">03</option>
<option value = "04">04</option>
<option value = "05">05</option>
<option value = "06">06</option>
<option value = "07">07</option>
<option value = "08">08</option>
<option value = "09">09</option>
<option value = "10">10</option>
<option value = "11">11</option>
<option value = "12">12</option>
<option value = "13">13</option>
<option value = "14">14</option>
<option value = "15">15</option>
<option value = "16">16</option>
<option value = "17">17</option>
<option value = "18">18</option>
<option value = "19">19</option>
<option value = "20">20</option>
<option value = "21">21</option>
<option value = "22">22</option>
<option value = "23">23</option>
<option value = "24">24</option>
<option value = "25">25</option>
<option value = "26">26</option>
<option value = "27">27</option>
<option value = "28">28</option>
<option value = "29">29</option>
<option value = "30">30</option>
<option value = "31">31</option>
</select>
<select id = "dob" name = "month">
<option value = "01">01</option>
<option value = "02">02</option>
<option value = "03">03</option>
<option value = "04">04</option>
<option value = "05">05</option>
<option value = "06">06</option>
<option value = "07">07</option>
<option value = "08">08</option>
<option value = "09">09</option>
<option value = "10">10</option>
<option value = "11">11</option>
<option value = "12">12</option>
</select>
<select id = "dob" name = "year">
<option value = "1887">1907</option>
<option value = "1888">1908</option>
<option value = "1899">1909</option>
<option value = "1900">1910</option>
<option value = "1901">1911</option>
<option value = "1902">1912</option>
<option value = "1903">1913</option>
<option value = "1904">1914</option>
<option value = "1905">1915</option>
<option value = "1906">1916</option>
<option value = "1907">1907</option>
<option value = "1908">1908</option>
<option value = "1909">1909</option>
<option value = "1910">1910</option>
<option value = "1911">1911</option>
<option value = "1912">1912</option>
<option value = "1913">1913</option>
<option value = "1914">1914</option>
<option value = "1915">1915</option>
<option value = "1916">1916</option>
<option value = "1917">1917</option>
<option value = "1918">1918</option>
<option value = "1919">1919</option>
<option value = "1920">1920</option>
<option value = "1921">1921</option>
<option value = "1922">1922</option>
<option value = "1923">1923</option>
<option value = "1924">1924</option>
<option value = "1925">1925</option>
<option value = "1926">1926</option>
<option value = "1927">1927</option>
<option value = "1928">1928</option>
<option value = "1929">1929</option>
<option value = "1930">1930</option>
<option value = "1931">1931</option>
<option value = "1932">1932</option>
<option value = "1933">1933</option>
<option value = "1934">1934</option>
<option value = "1935">1935</option>
<option value = "1936">1936</option>
<option value = "1937">1937</option>
<option value = "1938">1938</option>
<option value = "1939">1939</option>
<option value = "1940">1940</option>
<option value = "1941">1941</option>
<option value = "1942">1942</option>
<option value = "1943">1943</option>
<option value = "1944">1944</option>
<option value = "1945">1945</option>
<option value = "1946">1946</option>
<option value = "1947">1947</option>
<option value = "1948">1948</option>
<option value = "1949">1949</option>
<option value = "1950">1950</option>
<option value = "1951">1951</option>
<option value = "1952">1952</option>
<option value = "1953">1953</option>
<option value = "1954">1954</option>
<option value = "1955">1955</option>
<option value = "1956">1956</option>
<option value = "1957">1957</option>
<option value = "1958">1958</option>
<option value = "1959">1959</option>
<option value = "1960">1960</option>
<option value = "1961">1961</option>
<option value = "1962">1962</option>
<option value = "1963">1963</option>
<option value = "1964">1964</option>
<option value = "1965">1965</option>
<option value = "1966">1966</option>
<option value = "1967">1967</option>
<option value = "1968">1968</option>
<option value = "1969">1969</option>
<option value = "1970">1970</option>
<option value = "1971">1971</option>
<option value = "1972">1972</option>
<option value = "1973">1973</option>
<option value = "1974">1974</option>
<option value = "1975">1975</option>
<option value = "1976">1976</option>
<option value = "1977">1977</option>
<option value = "1978">1978</option>
<option value = "1979">1979</option>
<option value = "1980">1980</option>
<option value = "1981">1981</option>
<option value = "1982">1982</option>
<option value = "1983">1983</option>
<option value = "1984">1984</option>
<option value = "1985">1985</option>
<option value = "1986">1986</option>
<option value = "1987">1987</option>
<option value = "1988">1988</option>
<option value = "1989">1989</option>
<option value = "1990">1990</option>
<option value = "1991">1991</option>
<option value = "1992">1992</option>
<option value = "1993">1993</option>
<option value = "1994">1994</option>
<option value = "1995">1995</option>
<option value = "1996">1996</option>
<option value = "1997">1997</option>
<option value = "1998">1998</option>
<option value = "1999">1999</option>
<option value = "2000">2000</option>
<option value = "2001">2001</option>
<option value = "2002">2002</option>
<option value = "2003">2003</option>
<option value = "2004">2004</option>
<option value = "2005">2005</option>
<option value = "2006">2006</option>
<option value = "2007">2007</option>
<option value = "2008">2008</option>
<option value = "2009">2009</option>
<option value = "2010">2010</option>
<option value = "2011">2011</option>
<option value = "2012">2012</option>
<option value = "2013">2013</option>
<option value = "2014">2014</option>
<option value = "2015">2015</option>
<option value = "2016">2016</option>
<option value = "2017">2017</option>
</select>
<br />
<label>Does the patient have insurance?</label>
<input type = "radio" id = "insurance1" class = "insurance" name = "insurance" value = "Yes" onClick = "setInsurance_num();" checked = "checked">Yes</input>
<input type = "radio" id = "insurance2" class = "insurance" name = "insurance" value = "No" onClick = "setInsurance_num();">No</input>
<br /><br />
<label for = "insurance_num">Insurance Number:</label>
<input type = "text" id = "insurance_num" name = "insurance_num" maxlength = "5" pattern = "[0-9]{5}" autocomplete = "off" onkeypress = "return onlyNumbers(event,this);" />
<br />
<label>Patient type:</label>
<input type = "radio" id = "patient_type1" class = "patient_type" name = "patient_type" value = "Inpatient" onClick = "changeFields();" checked = "checked">Inpatient</input>
<input type = "radio" id = "patient_type2" class = "patient_type" name = "patient_type" value = "Outpatient" onClick = "changeFields();">Outpatient</input>
<br />
<h2>Medical Concerns:</h2>
<label for id = "medicalconcern">What is the primary medical problem or diagnosis for the appointment request?</label>
<input type = "textarea" rows = "4" id = "medicalconcern" name = "medicalconcern" maxlength = "150" pattern = "[a-Za-z0-9]{,150)" autocomplete = "off" onkeypress = "return onlyAlphanumeric(event,this);"/>
<br />
<p>IMPORTANT: After submission, please do not leave this form until you see the confirmation message.</p>
<input type = "submit" name = "submit" value= "Send Request" />
</form>
</div>
<div id = "appointment3">
<footer>
<ul>
<li>Contact number: 080-23450917, 080-23450918, 080-23450919, 080-23334565</li>
<li>© NMIT Foundation for Medical Education and Research (NMITMER). All rights reserved.</li>
</ul>
</footer>
</div>
</body>
</html>