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form1.html
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<!DOCTYPE html>
<html>
<head>
<meta name="viewport" content="width=device-width, initial-scale=1">
<style>
body{
font-family: Calibri, Helvetica, sans-serif;
background-color: pink;
}
.container {
padding: 50px;
background-color: lightblue;
}
input[type=text], input[type=password], textarea {
width: 100%;
padding: 15px;
margin: 5px 0 22px 0;
display: inline-block;
border: none;
background: #f1f1f1;
}
input[type=text]:focus, input[type=password]:focus {
background-color: orange;
outline: none;
}
div {
padding: 10px 0;
}
hr {
border: 1px solid #f1f1f1;
margin-bottom: 25px;
}
.registerbtn {
background-color: #4CAF50;
color: white;
padding: 16px 20px;
margin: 8px 0;
border: none;
cursor: pointer;
width: 100%;
opacity: 0.9;
}
.registerbtn:hover {
opacity: 1;
}
a{
text-decoration: none;
}
</style>
</head>
<body>
<form>
<div class="container">
<center> <h1> Patient Registeration Form</h1> </center>
<hr>
<label> Firstname </label>
<input type="text" name="firstname" placeholder= "Firstname" size="15" required />
<label> Middlename: </label>
<input type="text" name="middlename" placeholder="Middlename" size="15" required />
<label> Lastname: </label>
<input type="text" name="lastname" placeholder="Lastname" size="15"required />
<!-- <div>
<label>
Course :
</label>
<select>
<option value="Course">Course</option>
<option value="BCA">BCA</option>
<option value="BBA">BBA</option>
<option value="B.Tech">B.Tech</option>
<option value="MBA">MBA</option>
<option value="MCA">MCA</option>
<option value="M.Tech">M.Tech</option>
</select>
</div> -->
<div>
<label>
Gender :
</label><br>
<input type="radio" value="Male" name="gender" checked > Male
<input type="radio" value="Female" name="gender"> Female
<input type="radio" value="Other" name="gender"> Other
</div>
<label for="">
Age
</label>
<input type="number" name="age" id="">
<br>
<label>
Phone :
</label>
<input type="text" name="country code" placeholder="Country Code" value="+91" size="2"/>
<input type="text" name="phone" placeholder="phone no." size="10"/ required>
Current Address :
<textarea cols="80" rows="5" placeholder="Current Address" value="address" required>
</textarea>
<label for="email"><b>Email</b></label>
<input type="text" placeholder="Enter Email" name="email" required> <label>
Medicines
</label>
<textarea type="text" placeholder="Add Medicines"></textarea>
<!-- <label for="psw"><b>Password</b></label>
<input type="password" placeholder="Enter Password" name="psw" required>
<label for="psw-repeat"><b>Re-type Password</b></label>
<input type="password" placeholder="Retype Password" name="psw-repeat" required> -->
<button type="submit" class="registerbtn"><a href="qr.html">Update QR code</a></button>
</form>
</body>
</html>