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signup.php
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signup.php
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<?php
/**
* Created by IntelliJ IDEA.
* User: LR050891
* Date: 16-Mar-17
* Time: 3:09 PM
*/
include ('master\header.php');
include ('master.php');
?>
<section class="hero is-dark is-large">
<!-- Hero header: will stick at the top -->
<div class="hero-head">
<br>
<br>
<div class="column is-half is-offset-one-quarter"">
<form method="post" action="regsuccess.php">
<div class="box">
<div class="columns">
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="text" name="fname" required placeholder="First Name">
<span class="icon is-small"><i class="fa fa-info"></i></span>
</p>
</div>
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="text" name="lname" required placeholder="Last Name">
<span class="icon is-small"><i class="fa fa-info"></i></span>
</p>
</div>
</div>
<div class="columns">
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="text" name="username" required placeholder="UserName">
<span class="icon is-small"><i class="fa fa-user"></i></span>
</p>
</div>
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="email" name="email" required placeholder="Email">
<span class="icon is-small"><i class="fa fa-envelope"></i></span>
</p>
</div>
</div>
<div class="columns">
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="password" name="password" required placeholder="Password" maxlength="15">
<span class="icon is-small"><i class="fa fa-lock"></i></span>
</p>
</div>
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="password" required placeholder="Confirm Password">
<span class="icon is-small"><i class="fa fa-lock"></i></span>
</p>
</div>
</div>
<div class="columns">
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="number" name="age" required placeholder="Age" maxlength="15">
<span class="icon is-small"><i class="fa fa-lock"></i></span>
</p>
</div>
<div class="column is-6">
<p class="control has-icon">
<input class="input" type="tel" maxlength="10" name="mob" required placeholder="Mobile Number">
<span class="icon is-small"><i class="fa fa-lock"></i></span>
</p>
</div>
</div>
<div class="columns">
<div class="column is-6">
<div class="control">
<div class="select is-fullwidth">
<select required name="gender">
<option disabled selected >Gender</option>
<option>Male</option>
<option>Female</option>
</select>
</div>
</div>
</div>
<div class="column is-6">
<div class="control">
<div class="select is-fullwidth">
<select required name="blood">
<option disabled selected >Blood Group</option>
<option>A+</option>
<option>A-</option>
<option>B+</option>
<option>B-</option>
<option>AB+</option>
<option>AB-</option>
<option>O+</option>
<option>O-</option>
</select>
</div>
</div>
</div>
</div>
<div class="columns">
<div class="column is-offset-8">
<p class="control">
<input type="button" name="additional" class="button is-light" value="Add More details..">
</p>
</div>
<div class="column ">
<p class="control">
<input type="submit" name="signup" class="button is-info" value="Signup!">
</p>
</div>
</div>
</form>
</div>
<!-- Hero content: will be in the middle -->
<div class="hero-body">
<!-- <div class="container has-text-centered">
<h1 class="title">Patient Health Monitoring System</h1>
<h2 class="subtitle">Your Health is our health!</h2>
</div>-->
</div>
</section>