-
Notifications
You must be signed in to change notification settings - Fork 1
/
reciptDetailsForm.php
134 lines (101 loc) · 3.78 KB
/
reciptDetailsForm.php
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
<?php
include("db.php");
session_start();
?>
<?php
/**
* Created by PhpStorm.
* User: ruwan.wedisa
* Date: 6/1/2018
* Time: 9:03 AM
*/
$timeSlotNum = $_REQUEST['timeslot'];
$id=$_REQUEST['ID'];
$dayBooked = $_REQUEST['dayBooked'];
$name = $_REQUEST['Name'];
$date = $_REQUEST['Date'];
?>
<!doctype html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport"
content="width=device-width, user-scalable=no, initial-scale=1.0, maximum-scale=1.0, minimum-scale=1.0">
<meta http-equiv="X-UA-Compatible" content="ie=edge">
<title>Document</title>
<link rel = "stylesheet" href = "src/w3.css">
<link rel="stylesheet" href="src/css/bootstrap41/bootstrap.min.css">
<link href="src/css/font/fontawesome-free-5.0.12/web-fonts-with-css/css/fontawesome-all.css" rel="stylesheet">
<link rel="stylesheet" href="src/w3.css">
<link rel="stylesheet" href="src/font-awesome.min.css">
<link rel="stylesheet" href="src/web-fonts-with-css/css/fontawesome-all.min.css">
<link rel="stylesheet" href="src/css/bootstrap41/bootstrap.min.css">
<script src="src/js/jquery/331/jquery.min.js"></script>
<script src="src/js/popper.min.js"></script>
<script src="src/js/bootstrap41/bootstrap.min.js"></script>
<style>#div_color {
background-color: #E3E3E3;
}
</style>
</head>
<body>
<div id="container">
<?php include 'header.php'; ?>
</div>
<br><br><br>
<div class="w3-container w3-padding" >
<h2> <span><i class="fas fa-user-md fa-2x"></i> Dr.<?php echo $name?></span></h2>
</div>
<div class="w3-container w3-padding" >
<p style="color: #ff435b">Date:<?php echo $date?> </p>
</div>
<br>
<div class="w3-container w3-padding" id="div_color">
<h2>Enter Your Details</h2>
</div>
<br>
<div class="w3-container w3-margin " >
<form class = "w3-container w3-card-8" method="post" action="reciptDetails.php?ID=<?php echo $id?>×lot=<?php echo $timeSlotNum?>&dayBooked=<?php echo $dayBooked?>&Date=<?php echo $date?>">
<div class = "w3-group">
<label class = "w3-label"><b>Full Name</b></label>
<input class = "w3-input" name="name" type = "text" style = "width:90%" data-validation="required">
</div>
<div class = "w3-group">
<label class = "w3-label"><b>Phone</b></label>
<input class = "w3-input" name="pn" style = "width:90%"
data-validation="length" data-validation-length="8-9"
data-validation-error-msg="Telephone Number has to be a 9 numbers eg:71XXXXXXX"
placeholder="Type your telephone Number eg:71XXXXXXX"
>
</div>
<div class = "w3-group">
<label class = "w3-label"><b>NIC</b></label>
<input class = "w3-input" name="nic" style = "width:90%"
data-validation="length" data-validation-length="10-10"
data-validation-error-msg="Invalid NIC Number"
placeholder="eg:93XXXXXXXv"
>
</div>
<div class = "w3-group">
<label class = "w3-label"><b>Email</b></label>
<input class = "w3-input" name="email" type = "text" style = "width:90%"
data-validation="email"
>
</div>
<button type="submit" class="w3-button w3-block w3-quarter w3-red w3-section w3-ripple w3-padding" name="detailsSubmit">Continue</button>
</form>
</div>
</body>
</div>
<br><br><br><br>
<?php include 'footer.php'; ?>
</body>
</html>
<script type="text/javascript" src="src/js/jquery-3.2.1.min.js"></script>
<script type="text/javascript" src="src/js/bootstrap.min.js"></script>
<script src="src/js/jquery.form-validator.min.js"></script>
<script>
$.validate({
lang: 'en'
});
</script>