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ADSA_Clinic_PatientRegistration.htm
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ADSA_Clinic_PatientRegistration.htm
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<!DOCTYPE html>
<head>
<title>ADSA Login</title>
<link href="http://netdna.bootstrapcdn.com/twitter-bootstrap/2.3.0/css/bootstrap-combined.min.css" rel="stylesheet">
<link href="ADSA_Clinic_PatientRegistration.css" rel="stylesheet">
<link href="ADSA_Clinic_PatientRegistration_Custom_Classes.css" rel="stylesheet">
</head>
<html>
<body>
<div class="container" style="height: auto">
<div class="row">
<div class="span4">
<img src="/home/Alex/Documents/HTML/photos/adsa_icon.jpg" alt="head" width="411" height="100">
</div>
<div class="span2">
<div class="dropdown">
<button class="btn dropdown-toggle sr-only" type="button" id="dropdownMenu1" data-toggle="dropdown">
My Account
<span class="caret"></span>
</button>
<ul class="dropdown-menu" role="menu" aria-labelledby="dropdownMenu1">
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Account Info</a></li>
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Add/Edit Memberships</a></li>
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Configuration</a></li>
<li role="presentation" class="divider"></li>
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Edit Account Bar</a></li>
</ul>
</div>
</div>
<div class="span2">
<div class="dropdown">
<button class="btn dropdown-toggle sr-only" type="button" id="dropdownMenu1" data-toggle="dropdown">
Preferences
<span class="caret"></span>
</button>
<ul class="dropdown-menu" role="menu" aria-labelledby="dropdownMenu1">
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Page Setup</a></li>
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Colors</a></li>
<li role="presentation" class="divider"></li>
<li role="presentation"><a role="menuitem" tabindex="-1" href="#">Edit Preferences Bar</a></li>
</ul>
</div>
</div>
<div class="span2">
<button type="button" class="btn btn-default">Log Off</button>
</div>
</div>
<div class="row">
<div class='navbar navbar-inverse'>
<div class='navbar-inner nav-collapse' style="height: auto;">
<ul class="nav">
<li class="active"><a href="#">Home</a></li>
<li class="dropdown">
<a class="dropdown-toggle" data-toggle="dropdown" href="#">
Language <span class="caret"></span>
</a>
<ul class="dropdown-menu">
</ul>
</li>
<li><a href="pageOne.html">Info</a></li>
<li class="dropdown">
<a class="dropdown-toggle" data-toggle="dropdown" href="#">
Navigate<span class="caret"></span>
</a>
<ul class="dropdown-menu">
</ul>
</li>
<li class="active"><a href="#">Link</a></li>
<li class="dropdown">
<a class="dropdown-toggle" data-toggle="dropdown" href="#">
Favorites<span class="caret"></span>
</a>
<ul class="dropdown-menu">
</ul>
</li>
</ul>
</div>
</div>
</div>
</div>
<div class="row">
<div class="span2">
</div>
<div class="span3">
<div class="panel panel-default" style="background-color:#008B8B">
<div class="panel-heading">
<h3 class="panel-title">Help</h3>
</div>
<div class="panel-body">
<p>This is the help bar.
As you move through the
site, this bar will display
helpful information.
If you have a question,
type it into the search bar
below.</p>
<p>When you hover your mouse
over a part of the site,
some information about it
will be displayed here.</p>
<div class="input-group">
<span class="input-group-addon">Go</span>
<input type="text" class="form-control" placeholder="Search">
</div>
<li><a href="Register.html">Close</a></li>
</div>
</div>
</div>
<div class="span7">
<div class="row"><h1 style="text-align: center">Patient Registration</h1></div>
<div class="span7">
<div class="span2">
</div>
<div class="container" style="width: 670px;">
<div class="span8">
<div class="row">
<div class="span2">
<div class="input-group input-group-lg">
<span class="input-group-addon">First</span>
<input type="text" class="form-control" placeholder="Name">
</div>
<div class="input-group input-group-lg">
<span class="input-group-addon">Middle</span>
<input type="text" class="form-control" placeholder="Name">
</div>
<div class="input-group input-group-lg">
<span class="input-group-addon">Height</span>
<input type="text" class="form-control" placeholder="m">
</div>
</div>
<div class="span2">
<div class="input-group input-group-lg">
<span class="input-group-addon">Family</span>
<input type="text" class="form-control" placeholder="Name">
</div>
<div class="input-group input-group-lg">
<span class="input-group-addon">Second Middle</span>
<input type="text" class="form-control" placeholder="Name">
</div>
<div class="input-group input-group-lg">
<span class="input-group-addon">Height</span>
<input type="text" class="form-control" placeholder="cm">
</div>
</div>
<div class="span2">
<div class="input-group input-group-sm">
<span class="input-group-addon">Suffix</span>
<input type="text" class="form-control">
</div>
<div class="input-group input-group-sm">
<span class="input-group-addon">DOB</span>
<input type="text" class="form-control" placeholder="XX/XX/XXXX">
</div>
<div class="input-group input-group-sm">
<span class="input-group-addon">Gender</span>
<input type="text" class="form-control" placeholder="M/F">
</div>
</div>
<div class="span2">
<div class="input-group input-group-lg">
<span class="input-group-addon">Address</span>
<input type="text" class="form-control">
</div>
<div class="input-group input-group-lg">
<span class="input-group-addon">City</span>
<input type="text" class="form-control">
</div>
<div class="input-group input-group-sm">
<span class="input-group-addon">Province</span>
<input type="text" class="form-control">
</div>
</div>
</div>
<div class="row">
<div class="span4">
<div class="centered">
<button type="button" class="btn btn-primary">Submit</button>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</body>
</html>