-
Notifications
You must be signed in to change notification settings - Fork 2
/
register.html
151 lines (141 loc) · 8.68 KB
/
register.html
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
<!doctype html>
<html lang="en">
<meta http-equiv="content-type" content="text/html;charset=UTF-8" />
<head>
<meta charset="utf-8" />
<title> Register | CareWave Plus - Hospital & Clinic Management Laravel System </title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta content="Hospital Management System" name="description" />
<meta content="CareWave Plus" name="author" />
<!-- App favicon -->
<link rel="shortcut icon" href="build/images/favicon.ico">
<!-- App css -->
<link href="build/css/bootstrap.min.css" id="bootstrap-style" rel="stylesheet" type="text/css" />
<link href="build/css/icons.min.css" rel="stylesheet" type="text/css" />
<link href="build/css/app.min.css" id="app-style" rel="stylesheet" type="text/css" />
<link href="build/libs/toastr/build/toastr.min.css" rel="stylesheet" type="text/css">
</head>
<body>
<div id="preloader">
<div id="status">
<div class="spinner-chase">
<div class="chase-dot"></div>
<div class="chase-dot"></div>
<div class="chase-dot"></div>
<div class="chase-dot"></div>
<div class="chase-dot"></div>
<div class="chase-dot"></div>
</div>
</div>
</div>
<div class="account-pages my-5 pt-5">
<div class="container">
<div class="row justify-content-center">
<div class="col-md-8 col-lg-6 col-xl-5">
<div class="card overflow-hidden">
<div class="bg-primary-subtle">
<div class="row">
<div class="col-7">
<div class="text-primary p-4">
<h5 class="text-primary">Patient Register</h5>
<p>Get your free CareWave Plus Patient account now.</p>
</div>
</div>
<div class="col-5 align-self-end">
<img src="build/images/profile-img.png" alt="" class="img-fluid">
</div>
</div>
</div>
<div class="card-body pt-0">
<div class="auth-logo">
<a href="login.html" class="auth-logo-light">
<div class="avatar-md profile-user-wid mb-4">
<span class="avatar-title rounded-circle bg-light">
<img src="build/images/logo-light.html" alt="" class="rounded-circle"
height="34">
</span>
</div>
</a>
<a href="login.html" class="auth-logo-dark">
<div class="avatar-md profile-user-wid mb-4">
<span class="avatar-title rounded-circle bg-light">
<img src="build/images/logo.svg" alt="" class="rounded-circle"
height="34">
</span>
</div>
</a>
</div>
<div class="p-2">
<form method="POST" class="form-horizontal"
action="https://doctorly.themesbrand.website/register">
<input type="hidden" name="_token"
value="kqR9mIk75Jl9DR2rMb8m4BDBni77PzuZYWjnzGW5">
<div class="mb-3">
<label for="first_name">First Name <span
class="text-danger">*</span></label>
<input type="text" class="form-control " value="" name="first_name"
id="userfirstname" placeholder="Enter First Name">
</div>
<div class="mb-3">
<label for="last_name">Last Name <span class="text-danger">*</span></label>
<input type="text" class="form-control " value="" name="last_name"
id="userlastname" placeholder="Enter Last Name">
</div>
<div class="mb-3">
<label for="usermobile">Contact No <span
class="text-danger">*</span></label>
<input type="tel" class="form-control " value="" name="mobile"
id="usermobile" placeholder="Enter Contact Number">
</div>
<div class="mb-3">
<label for="useremail">Email <span class="text-danger">*</span></label>
<input type="email" class="form-control " value="" id="useremail"
name="email" placeholder="Enter email">
</div>
<div class="mb-3">
<label for="userpassword">Password <span
class="text-danger">*</span></label>
<input type="password" class="form-control " value="" name="password"
id="userpassword" placeholder="Enter password">
</div>
<div class="mb-3">
<label for="userpassword">Confirm Password <span
class="text-danger">*</span></label>
<input id="password-confirm" type="password" name="password_confirmation"
class="form-control " placeholder="Enter confirm password ">
</div>
<div class="mt-4">
<button class="btn btn-primary w-100 waves-effect waves-light"
type="submit">Register</button>
</div>
<div class="mt-4 text-center">
<p class="mb-0">By registering you agree to the CareWave Plus <a href="#"
class="text-primary">Terms of Use</a></p>
</div>
</form>
</div>
</div>
</div>
<div class="mt-5 text-center">
<p>Already have an account ? <a href="login.html" class="fw-medium text-primary">Login </a>
</p>
<p>© 2024 CareWave Plus. Crafted with <i class="mdi mdi-heart text-danger"></i> by DreamersDesire
</p>
</div>
</div>
</div>
</div>
</div>
<!-- JAVASCRIPT -->
<script src="build/libs/jquery/jquery.min.js"></script>
<script src="build/libs/bootstrap/js/bootstrap.bundle.min.js"></script>
<script src="build/libs/metismenu/metisMenu.min.js"></script>
<script src="build/libs/simplebar/simplebar.min.js"></script>
<script src="build/libs/node-waves/waves.min.js"></script>
<script src="build/libs/toastr/toastr.js"></script>;
<!-- App js -->
<script src="build/js/app.min.js"></script>
<script>
</script>
</body>
</html>