This repository has been archived by the owner on Mar 17, 2024. It is now read-only.
-
Notifications
You must be signed in to change notification settings - Fork 0
/
Copy pathappointment.html
87 lines (86 loc) · 3 KB
/
appointment.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
<!DOCTYPE HTML>
<html>
<head>
<title>Appointment Form</title>
<meta name="viewport" content="width=device-width, initial-scale=1">
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<script type="application/x-javascript"> addEventListener("load", function() { setTimeout(hideURLbar, 0); }, false); function hideURLbar(){ window.scrollTo(0,1); } </script>
<link href="css/wickedpicker.css" rel="stylesheet" type='text/css' media="all" />
<link href="css/styleapp.css" rel='stylesheet' type='text/css' />
<link href="//fonts.googleapis.com/css?family=Roboto:300,400,500,700" rel="stylesheet">
<link href="//fonts.googleapis.com/css?family=Droid+Sans:400,700" rel="stylesheet">
</head>
<body>
<h1> Medical Appointment Form </h1>
<div class="bg-agile">
<div class="book-appointment">
<h2>Make an appointment</h2>
<form action="#" method="post">
<div class="left-agileits-w3layouts same">
<div class="gaps">
<p>Patient Name</p>
<input type="text" name="Patient Name" placeholder="" required=""/>
</div>
<div class="gaps">
<p>Phone Number</p>
<input type="text" name="Number" placeholder="" required=""/>
</div>
<div class="gaps">
<p>Email</p>
<input type="email" name="email" placeholder="" required="" />
</div>
<div class="gaps">
<p>Symptoms</p>
<textarea name="About Symptoms" placeholder="" required="" ></textarea>
</div>
</div>
<div class="right-agileinfo same">
<div class="gaps">
<p>Select Date</p>
<input id="datepicker1" name="Text" type="text" value="" onfocus="this.value = '';" onblur="if (this.value == '') {this.value = 'mm/dd/yyyy';}" required="">
</div>
<div class="gaps">
<p>Department</p>
<select class="form-control">
<option></option>
<option>Cardiology</option>
<option>Ophthalmology</option>
<option>Neurology</option>
<option>Psychology</option>
<option>Dermatology</option>
</select>
</div>
<div class="gaps">
<p>Gender</p>
<select class="form-control">
<option></option>
<option>Male</option>
<option>Female</option>
</select>
</div>
<div class="gaps">
<p>Time</p>
<input type="text" id="timepicker" name="Time" class="timepicker form-control" value="">
</div>
</div>
<div class="clear"></div>
<input type="submit" value="Make an appointment">
</form>
</div>
</div>
<script type="text/javascript" src="js/jquery-2.1.4.min.js"></script>
<script type="text/javascript" src="js/wickedpicker.js"></script>
<script type="text/javascript">
$('.timepicker').wickedpicker({twentyFour: false});
</script>
<!-- Calendar -->
<link rel="stylesheet" href="css/jquery-ui.css" />
<script src="js/jquery-ui.js"></script>
<script>
$(function() {
$( "#datepicker,#datepicker1,#datepicker2,#datepicker3" ).datepicker();
});
</script>
<!-- //Calendar -->
</body>
</html>