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Register.php
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Register.php
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<!DOCTYPE html>
<html lang="en">
<head>
<!-- Basic Page Needs
================================================== -->
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<title>SPA Pathcare : Register</title>
<!-- Mobile Specific Metas
================================================== -->
<meta name="viewport" content="width=device-width, initial-scale=1">
<!-- Favicon -->
<link rel="shortcut icon" type="image/icon" href="images/favicon.ico"/>
<!-- CSS
================================================== -->
<!-- Bootstrap css file-->
<link href="css/bootstrap.min.css" rel="stylesheet">
<!-- Font awesome css file-->
<link href="css/font-awesome.min.css" rel="stylesheet">
<!-- Default Theme css file -->
<link id="switcher" href="css/themes/orange-theme.css" rel="stylesheet">
<!-- Slick slider css file -->
<link href="css/slick.css" rel="stylesheet">
<!-- Main structure css file -->
<link href="style.css" rel="stylesheet">
<!-- Google fonts -->
<link href="http://fonts.googleapis.com/css?family=Raleway" rel="stylesheet" type="text/css">
<link href="http://fonts.googleapis.com/css?family=Habibi" rel="stylesheet" type="text/css">
<link href="http://fonts.googleapis.com/css?family=Cinzel+Decorative:900" rel="stylesheet" type="text/css">
<!-- HTML5 shim and Respond.js for IE8 support of HTML5 elements and media queries -->
<!-- WARNING: Respond.js doesn't work if you view the page via file:// -->
<!--[if lt IE 9]>
<script src="https://oss.maxcdn.com/html5shiv/3.7.2/html5shiv.min.js"></script>
<script src="https://oss.maxcdn.com/respond/1.4.2/respond.min.js"></script>
<![endif]-->
</head>
<body>
<!-- BEGAIN PRELOADER -->
<div id="preloader">
<div id="status"> </div>
</div>
<!-- END PRELOADER -->
<!-- SCROLL TOP BUTTON -->
<a class="scrollToTop" href="#"><i class="fa fa-heartbeat"></i></a>
<!-- END SCROLL TOP BUTTON -->
<!--=========== BEGIN HEADER SECTION ================-->
<header id="header">
<!-- BEGIN MENU -->
<div class="menu_area">
<nav class="navbar navbar-default navbar-fixed-top" role="navigation">
<div class="container">
<div class="navbar-header">
<!-- FOR MOBILE VIEW COLLAPSED BUTTON -->
<button type="button" class="navbar-toggle collapsed" data-toggle="collapse" data-target="#navbar" aria-expanded="false" aria-controls="navbar">
<span class="sr-only">Toggle navigation</span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
<span class="icon-bar"></span>
</button>
<!-- LOGO -->
<!-- TEXT BASED LOGO -->
<a class="navbar-brand" href="index.php"><i class="fa fa-heartbeat"></i>SpA <span>Pathcare</span></a>
<!-- IMG BASED LOGO -->
<!-- <a class="navbar-brand" href="index.php"><img src="images/logo.png" alt="logo"></a> -->
</div>
<!--/.nav-collapse -->
<?php include ("menu.php") ?>
</div>
</nav>
</div>
<!-- END MENU -->
</header>
<!--=========== END HEADER SECTION ================-->
<section id="blogArchive">
<div class="row">
<div class="col-lg-12 col-md-12">
<div class="blog-breadcrumbs-area">
<div class="container">
<div class="blog-breadcrumbs-left">
<h2>Registration</h2>
</div>
<div class="blog-breadcrumbs-right">
<ol class="breadcrumb">
<li>You are here</li>
<li><a href="#">Home</a></li>
<li class="active">Register</li>
</ol>
</div>
</div>
</div>
</div>
</div>
</section>
<!--=========== BEGAIN Doctors SECTION ================-->
<section id="meetDoctors">
<div class="container">
<div class="row">
<div class="col-lg-12 col-md-12">
<div class="meetDoctors-area">
<!-- Start Service Title -->
<div class="section-heading">
<h2>Register Here</h2>
<div class="line"></div>
</div>
<div class="modal-body" style="margin-left:25%">
<div class="appointment-area">
<form class="appointment-form" action="registration.php" method="post">
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Your name <span class="required">*</span></label>
<input type="text" class="wp-form-control wpcf7-text" placeholder="First name" name="fname" required pattern="[A-Za-z-0-9]+"><input type="text" class="wp-form-control wpcf7-text" placeholder="Last name" name="lname" required pattern="[A-Za-z-0-9]+">
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Your Email <span class="required">*</span></label>
<input type="email" class="wp-form-control wpcf7-email" placeholder="Email address" name="mail" required>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Your Birth <span class="required">*</span></label>
<input type="date" class="wp-form-control wpcf7-text" placeholder="dd/mm/yy" max="<?php echo date("Y-m-d"); ?>" name="dob" required>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Select Gender <span class="required">*</span></label>
<select class="wp-form-control wpcf7-select" name="gnd" required>
<option val="Undefined">Select Gender</option>
<option val="Male">Male</option>
<option val="Female">Female</option>
</select>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Your Address <span class="required">*</span></label>
<input type="text" class="wp-form-control wpcf7-text" placeholder="Your Address" name="addr" required>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Your Phone <span class="required">*</span></label>
<input type="number" class="wp-form-control wpcf7-text" placeholder="Phone No" name="phno" required>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Your Password <span class="required">*</span></label>
<input type="password" class="wp-form-control wpcf7-text" placeholder="Your Password" name="pwd" required>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6">
<label class="control-label">Retype Password <span class="required">*</span></label>
<input type="password" class="wp-form-control wpcf7-text" placeholder="Retype Password" name="repwd" required>
</div>
</div>
<button class="wpcf7-submit button--itzel" type="submit"><i class="button__icon fa fa-share"></i><span>Register</span></button>
</form>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<!--=========== End Doctors SECTION ================-->
<!--=========== BEGAIN Counter SECTION ================-->
<?php include('counter.php') ?>
<!--=========== End Counter SECTION ================-->
<!--=========== Start Footer SECTION ================-->
<?php include('footer.php') ?>
<!--=========== End Footer SECTION ================-->
<!-- jQuery Library -->
<script src="js/jquery.js"></script>
<!-- Bootstrap default js -->
<script src="js/bootstrap.min.js"></script>
<!-- slick slider -->
<script src="js/slick.min.js"></script>
<script type="text/javascript" src="js/modernizr.custom.79639.js"></script>
<!-- counter -->
<script src="js/waypoints.min.js"></script>
<script src="js/jquery.counterup.min.js"></script>
<!-- Doctors hover effect -->
<script src="js/snap.svg-min.js"></script>
<script src="js/hovers.js"></script>
<!-- Photo Swipe Gallery Slider -->
<script src="js/photoswipe.min.js"></script>
<script src="js/photoswipe-ui-default.min.js"></script>
<script src="js/photoswipe-gallery.js"></script>
<!-- Custom JS -->
<script src="js/custom.js"></script>
</body>
</html>