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ADSA_Clinic_PatientRegistration_V2.htm
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<!DOCTYPE html PUBLIC "-//W3C//DTD HTML 4.01//EN">
<html>
<head>
<link href="bootstrap/css/bootstrap.min.css" rel="stylesheet" type=
"text/css">
<link href="test.css" rel="stylesheet" type="text/css">
<title></title>
</head>
<body>
<div class="container-fluid">
<div class="row-fluid">
<div class="span8 offset2 contentarea">
<div class="row-fluid">
<div class="span12">
<img alt="head" src=
"/home/Alex/Documents/HTML/photos/adsa_icon.jpg" style=
"display:inline; width:411px;height:100px;">
<div class="dropdown" style="display:inline-block; float:right;">
<button class="btn dropdown-toggle sr-only" data-toggle=
"dropdown" id="dropdownMenu1" type="button">My Account</button>
<ul class="dropdown-menu">
<li><a href="#" tabindex="-1">Account Info</a></li>
<li><a href="#" tabindex="-1">Add/Edit Memberships</a></li>
<li><a href="#" tabindex="-1">Configuration</a></li>
<li><a href="#" tabindex="-1">Edit Account Bar</a></li>
</ul>
</div>
<div class="dropdown" style="display:inline-block; float:right;">
<button class="btn dropdown-toggle sr-only" data-toggle=
"dropdown" id="dropdownMenu1" type="button">Preferences</button>
<ul class="dropdown-menu">
<li><a href="#" tabindex="-1">Page Setup</a></li>
<li><a href="#" tabindex="-1">Colors</a></li>
<li><a href="#" tabindex="-1">Edit Preferences Bar</a></li>
</ul>
</div><button class="btn btn-default" style=
"display:inline-block; float:right;" type="button">Log Off</button>
</div>
</div>
<div class="row-fluid">
<div class="span12">
<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</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</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</a>
<ul class="dropdown-menu"></ul>
</li>
</ul>
</div>
</div>
</div>
</div>
<div class="row-fluid">
<div class="span4">
<div class="panel panel-default" style="background-color:#008B8B; padding:10px;">
<div class="panel-heading">
<h3 class="panel-title" style="margin-top:0px;">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>
<form class="form">
<div class="input-prepend">
<span class="add-on">Go</span>
<input class="span12" id="prependedInput" type="text" placeholder="Search">
</div>
</form>
<a href="Register.html" class="btn btn-primary">Close</a>
</div>
</div>
</div>
<div class="span8">
<div class="row-fluid">
<h1 style="text-align: center; margin-top:0px;">Patient Registration</h1>
</div>
<div class="row-fluid">
<div class="span10 offset1">
<div class="row">
<table class="table table-bordered" bgcolor="green">
<tbody>
<tr class="info">
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">First</span>
<input type="text" class="form-control" placeholder="Name" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">Family</span>
<input type="text" class="form-control" placeholder="Name" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-sm">
<span class="input-group-addon">Suffix</span>
<input type="text" class="form-control" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">Address</span>
<input type="text" class="form-control" style="width:80px">
</div>
</td>
</tr>
<tr class="info">
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">Middle</span>
<input type="text" class="form-control" placeholder="Name" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">Second Middle</span>
<input type="text" class="form-control" placeholder="Name" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-sm">
<span class="input-group-addon">DOB</span>
<input type="text" class="form-control" placeholder="XX/XX/XXXX" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">City</span>
<input type="text" class="form-control" style="width:80px">
</div>
</td>
</tr>
<tr class="info">
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">Height</span>
<input type="text" class="form-control" placeholder="m" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-lg">
<span class="input-group-addon">Height</span>
<input type="text" class="form-control" placeholder="cm" style="width:80px">
</div>
</td>
<td>
<div class="input-group input-group-sm">
<span class="input-group-addon">Gender</span>
<input type="text" class="form-control" placeholder="M/F" style="width:80px">
</div>
</td>
<td>
<div class="span6 offset3">
<button class="btn btn-primary" style="margin-top: 15px; margin-left: 2px" type="button">Submit</button>
</div>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</body>
</html>