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42 views4 pages

M

Uploaded by

Mika Dela Cruz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as TXT, PDF, TXT or read online on Scribd
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<!

DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Patient Information</title>

<!-- Include Font Awesome for icons -->


<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-
awesome/6.2.0/css/all.min.css">
<!-- Include Select2 CSS -->
<link
href="https://cdnjs.cloudflare.com/ajax/libs/select2/4.0.13/css/select2.min.css"
rel="stylesheet" />
<!-- Custom CSS -->
<link rel="stylesheet" href="css/style.css">

<!-- Inline CSS for form styling -->


<style>
body {
font-family: 'Arial', sans-serif;
line-height: 1.6;
padding: 10px;
background: linear-gradient(to right, #2c3e50, #3498db);
color: #333;
}
.form-container {
width: 60%;
margin: 20px auto;
background-color: #ffffff;
padding: 20px;
border-radius: 8px;
box-shadow: 0 0 10px rgba(0, 0, 0, 0.1);
color: #333;
}
.form-container h3 {
text-align: center;
margin-bottom: 20px;
font-size: 24px;
color: #3498db;
}
.form-group {
margin-bottom: 20px;
}
.form-group label {
display: block;
font-weight: bold;
margin-bottom: 8px;
font-size: 16px;
color: #2c3e50;
}
.form-group input[type="text"],
.form-group input[type="email"],
.form-group input[type="password"],
.form-group input[type="number"],
.form-group input[type="date"],
.form-group select,
.select2-container--default .select2-selection--single {
width: 100%;
padding: 12px;
border: 1px solid #ccc;
border-radius: 6px;
box-sizing: border-box;
font-size: 16px;
}
.select2-container--default .select2-selection--single {
height: auto;
padding: 6px;
}
.form-group input[type="submit"] {
background-color: #3498db;
color: white;
padding: 12px 24px;
border: none;
border-radius: 6px;
cursor: pointer;
font-size: 16px;
}
.form-group input[type="submit"]:hover {
background-color: #2980b9;
}
.message {
padding: 10px;
background-color: #4CAF50;
color: white;
text-align: center;
margin-bottom: 20px;
border-radius: 6px;
}
.error-message {
padding: 10px;
background-color: #f44336;
color: white;
text-align: center;
margin-bottom: 20px;
border-radius: 6px;
}
</style>
</head>
<body>

<section class="form-container">
<h3>Patient Form</h3>

<form action="patient.php" method="post">


<div class="form-group">
<label for="date">Date:</label>
<input type="date" id="date" name="date" placeholder="Date" required>
</div>

<div class="form-group">
<label for="name">Name:</label>
<input type="text" id="name" name="name" placeholder="Name" required>
</div>

<div class="form-group">
<label for="case_number">Case Number:</label>
<input type="text" id="case_number" name="case_number" placeholder="Case
Number">
</div>

<div class="form-group">
<label for="category">Category:</label>
<select id="category" name="category" class="select2">
<option value="" disabled selected>Category</option>
<option value="Charity Male Out-Patient">Charity Male
Out-Patient</option>
<option value="Charity Female Out-Patient">Charity Female Out-
Patient</option>
<option value="Charity Male In-Patient">Charity Male
In-Patient</option>
<option value="Charity Female In-Patient">Charity Female
In-Patient</option>
<option value="Pay Male Out-Patient">Pay Male Out-Patient</option>
<option value="Pay Female Out-Patient">Pay Female Out-Patient</option>
<option value="Pay Male In-Patient">Pay Male In-Patient</option>
<option value="Pay Female In-Patient">Pay Female In-Patient</option>
<option value="Charity Male ER-Patient">Charity Male
ER-Patient</option>
<option value="Charity Female ER-Patient">Charity Female
ER-Patient</option>
</select>
</div>

<div class="form-group">
<label for="procedure_category">Procedure Category:</label>
<select id="procedure_category" name="procedure_category" class="select2"
required>
<option value="" disabled selected>Procedure Category</option>
<option value="Procedure Charity Male Out-Patient">Procedure Charity
Male Out-Patient</option>
<option value="Procedure Charity Female Out-Patient">Procedure Charity
Female Out-Patient</option>
<option value="Procedure Pay Male Out-Patient">Procedure Pay Male Out-
Patient</option>
<option value="Procedure Pay Female Out-Patient">Procedure Pay Female
Out-Patient</option>
</select>
</div>

<div class="form-group">
<label for="philhealth">Philhealth:</label>
<select id="philhealth" name="philhealth" class="select2">
<option value="" disabled selected>Philhealth</option>
<option value="Philhealth Charity Male">Philhealth Charity
Male</option>
<option value="Philhealth Charity Female">Philhealth Charity
Female</option>
<option value="Philhealth Pay Male">Philhealth Pay Male</option>
<option value="Philhealth Pay Female">Philhealth Pay Female</option>
</select>
</div>

<div class="form-group">
<label for="procedure">Procedure:</label>
<select id="procedure" name="procedure" class="select2" required>
<option value="" disabled selected>Procedure</option>
<option value="Ocular Ultrasound (UTZ)">Ocular Ultrasound
(UTZ)</option>
<!-- Add other procedure options here -->
</select>
</div>

<div class="form-group">
<label for="laterality">Laterality:</label>
<select id="laterality" name="laterality" class="select2" required>
<option value="" disabled selected>Laterality</option>
<option value="Right Eye (OD)">Right Eye (OD)</option>
<option value="Left Eye (OS)">Left Eye (OS)</option>
<option value="Both Eyes (OU)">Both Eyes (OU)</option>
</select>
</div>

<div class="form-group">
<label for="receipt_number">Receipt Number:</label>
<input type="text" id="receipt_number" name="receipt_number"
placeholder="Receipt Number">
</div>

<div class="form-group">
<input type="submit" value="Submit">
</div>
</form>
</section>

</body>
</html>

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