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REGISTRATION1.html
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<html>
<head>
<title>Registration</title>
<link rel="icon" href="hos1.png" type="image/x-icon">
<link rel="stylesheet" href="REGISTRATION.css">
<script>
function goBack()
{
window.history.back()
}
function goForward()
{
window.history.forward()
}
</script>
</head>
<body bgcolor="mistyrose">
<table>
<tr>
<td><img src="hos1.png"></h1></I></td>
<td style="font-size:50px;">
<font color="#428bca"> LIFE MATTERS </font>
<font color="#000"> Hospital</font>
</td>
</tr>
</table>
<!--
-->
<center>
<div class="view">
<div>
<table width="100%">
<tr>
<font size="4px" >
<th ><input type="button" class="bt" value="<" onclick="goBack()" ></th>
<th><a href="index.html " style=" color: white" ><b>HOME</b></a> </th>
<th><a href="REGISTRATION1.html" style=" color: white"><b>REGISTRATION </b></a></th>
<th><a href="a.html" style=" color: white"><b>SPECIALIZATION</b></a></th>
<th><a href="Procedures.html" style=" color: white"><b>PROCEDURES</b></a> </th>
<th><a href="LOCATIONS.html" style="color: white"> <b>LOCATIONS</b> </a></th>
<th><input type="button" class="bt" value=">" onclick="goForward()"></th>
</font>
</tr>
</table>
</div>
</div>
</center> <div class="myDiv2">
<h1 align="center"><u>NEW REGISTRATION</u></h1>
<h3 align="center">Note: Column marked with * are compulsory to fill in.</h3>
<br>
<form action="registration.php" method="POST">
<table>
<thead>
<tr>
<th>
<div class="myDiv">
<h2 class="header">Identification Details</h2>
<label for="initial">Initial: </label>
<select name="initial">
<option value="">Select Initial</option>
<option value="Mr">Mr.</option>
<option value="Ms.">Ms.</option>
<option value="Mastr.">Mastr.</option>
<option value="Smt.">Smt.</option>
<option value="Mrs.">Mrs.</option>
<option value="Miss.">Miss.</option>
<option value="Dr.">Dr.</option>
<option value="Baby">Baby.</option>
</select><br><br>
<label for="fname">*First name:</label>
<input type="text" id="fname" name="fname" placeholder="Enter First Name" required><br><br>
<label for="lname">*Last name:</label>
<input type="text" id="lname" name="lname" placeholder="Enter Last Name" required><br><br>
<label for="contact">Contact number: </label>
<input type="number" id="contact" name="contact" placeholder="Enter Contact Number"><br><br>
<label for="email">Email ID:</label>
<input type="text" id="email" name="email" placeholder="Enter Email id"><br><br>
</div>
<div class="myDiv4">
<br>
<h2 class="header">Referral Information</h2>
<br>
<label for="referral">Referred By Doctor/Hospital Clinic: </label>
<input type="text" id="referral" name="referral" placeholder="Enter Referral Name"><br><br>
<br>
<label for="reAddress">Address of Referring doctor Clinic: </label>
<input type="text" id="readdress" name="reAddress" placeholder="Refferal Adders"><br><br></input>
<br>
<label for="referred">Referred For: </label>
<select name="referred">
<option value="">Select referred</option>
<option value="TREATMENT">TREATMENT</option>
<option value="EVALUATION">EVALUATION</option>
<option value="FOLLOWUP">FOLLOWUP</option>
<option value="INVESTIGATION">INVESTIGATION</option>
<option value="MEDICAL">MEDICAL</option>
<option value="MINOR OT">MINOR OT</option>
<option value="NO RS">NO RS</option>
<option value="OT">OT</option>
<option value="PLANNING">PLANNING</option>
<option value="REVIEW">REVIEW</option>
<option value="SCOPY">SCOPY</option>
</select>
</div>
</th>
<br>
<th>
<div class="myDiv3">
<h2 class="header">Personal Information</h2><br>
<label for="dob">*DOB: </label>
<input type="date" id="dob" name="dob" required><br><br></input>
<label for="gender">*Gender: </label>
<select name="gender" required>
<option value="">Select gender</option>
<option value="M">Male</option>
<option value="F">Female</option>
<option value="o">others</option>
</select>
<br><br>
<label for="MStatus">Marital Status: </label>
<select name="MStatus">
<option value="">Select MStatus</option>
<option value="UNMARRIED">UNMARRIED</option>
<option value="MARRIED">MARRIED</option>
<option value="WIDOWER">WIDOWER</option>
<option value="DIVORCED">DIVORCED</option>
<option value="SEPERATED">SEPERATED</option>
<option value="WIDOW">WIDOW</option>
<option value="OTHERS">OTHERS</option>
<option value="UNKNOWN">UNKNOWN</option>
</select><br><br>
<label for="fathername">Father/Spouse's Name: </label>
<input type="text" id="fathername" name="fathername"
placeholder="Enter Father/Spouse's Name"><br><br></input>
<label for="Education">*Education: </label>
<select name="Education" required>
<option value="">Select Education</option>
<option value="ILLITERATE">ILLITERATE</option>
<option value="LITERATE">LITERATE</option>
<option value="PRIMARY">PRIMARY</option>
<option value="MIDDLE">MIDDLE</option>
<option value="SECONDARY">SECONDARY</option>
<option value="TECHNICAL">TECHNICAL</option>
<option value="COLLEGE AND ABOVE">COLLEGE AND ABOVE</option>
<option value="OTHERS">OTHERS</option>
<option value="UNKNOWN">UNKNOWN</option>
<option value="LESS THAN 5 YRS OLD">LESS THAN 5 YRS OLD</option>
</select><br><br>
<label for="Occupation">Occupation: </label>
<select name="Occupation">
<option value="">Select Occupation</option>
<option value="BUSINESS">BUSINESS</option>
<option value="HOUSE WIFE">HOUSE WIFE</option>
<option value="SERVICE">SERVICE</option>
<option value="PENSIONER">PENSIONER</option>
<option value="RETIRED">RETIRED</option>
<option value="STUDENT">STUDENT</option>
<option value="UNEMPLOYED">UNEMPLOYED</option>
<option value="OTHERS">OTHERS</option>
<option value="AGRICULTURE">AGRICULTURE</option>
<option value="UNKNOWN">UNKNOWN</option>
</select><br><br>
<label for="fim">Family Income Monthly (Rs.): </label>
<input type="text" id="fim" name="fim" placeholder="Enter Family Income"><br><br></input>
<label for="Nationality">*Nationality: </label>
<select name="Nationality" required>
<option value="">Select Nationality</option>
<option value="Indian">Indian</option>
<option value="Foreign">Foreign</option>
<option value="UNKNOWN">UNKNOWN</option>
</select><br><br>
<label for="Religion">Religion: </label>
<select name="Religion" required>
<option value="">Select Religion</option>
<option value="ANGLO INDIAN">ANGLO INDIAN</option>
<option value="CHRISTIAN">CHRISTIAN</option>
<option value="HINDU">HINDU</option>
<option value="JAIN">JAIN</option>
<option value="JEW">JEW</option>
<option value="MUSLIM">MUSLIM</option>
<option value="NEO-BUDDHIST">NEO-BUDDHIST</option>
<option value="OTHERS">OTHERS</option>
<option value="PARSI">PARSI</option>
<option value="SIKH">SIKH</option>
<option value="UNKNOWN">UNKNOWN</option>
</select><br><br>
<label for="Mother_Tongue">*Mother Tongue: </label>
<select name="Mother_Tongue" required>
<option value="">Select Mother Tongue</option>
<option value="ASSAMESE">ASSAMESE</option>
<option value="BENGALI">BENGALI</option>
<option value="ENGLISH">ENGLISH</option>
<option value="GUJARATHI">GUJARATHI</option>
<option value="HINDI">HINDI</option>
<option value="KANNADA">KANNADA</option>
<option value="KASHMIRI">KASHMIRI</option>
<option value="kONKANI">kONKANI</option>
<option value="MALAYALAM">MALAYALAM</option>
<option value="MARATHI">MARATHI</option>
<option value="MARWARI">MARWARI</option>
<option value="NEPALI">NEPALI</option>
<option value="ORIYA">ORIYA</option>
<option value="OTHERS">OTHERS</option>
<option value="PUNJABI">PUNJABI</option>
<option value="RAJASTHANI">RAJASTHANI</option>
<option value="SANSKRIT">SANSKRIT</option>
<option value="SINDHI">SINDHI</option>
<option value="TAMIL">TAMIL</option>
<option value="TELUGU">TELUGU</option>
<option value="TULU">TULU</option>
<option value="UNKNOWN">UNKNOWN</option>
<option value="URDU">URDU</option>
</select><br><br>
<label for="Pan_No">Pan No.: </label>
<input type="text" name="Pan_No" placeholder="Enter Pan No."><br><br></input>
<label for="Aadhaar_Number">Aadhaar Number: </label>
<input type="text" name="Aadhaar_Number" placeholder="Enter Aadhaar Number"><br><br></input>
</div>
</div>
</th>
</thead>
</table>
<br>
<br><br>
<br><br>
<br>
<center style="font-size: 15px;">
<h3>
<label for="Medical_Insurance">Medical Insurance :
<input id="Yes" name="Medical_Insurance" type="radio" value="true" />Yes
<input id="No" name="Medical_Insurance" type="radio" value="False" />No
</h3>
</label>
<h3><input type="checkbox" id="tc" name="tc" value="true" required>
<b>I understand and agree to provide personal information.*</b>
</h3>
<input type="submit" />
<button type="reset" value="Reset"><a href="REGISTRATION1.html">Reset</a></button>
<br><br>
<br>
</div>
</form>
<div class="footer">
<table >
<th>
<ul style="margin-bottom: 100px;" >
<h3>
<li style="color: palevioletred">About us</li>
<hr style="background-color: rgb(80, 60, 60); width: 100px;height: 1px;margin-top: 0px; margin-bottom: 30px;">
<li style="color:pink; text-shadow: 2px 2px 5px ">“Our mission is to bring healthcare of International standards within the reach of every individual. </li>
<li style="color:pink; text-shadow: 2px 2px 5px "> We are committed to the achievement and maintenance of excellence in education, research and </li>
<li style="color:pink; text-shadow: 2px 2px 5px "> healthcare for the benefit of humanity”</li>
</h3>
</ul>
</th>
<th>
<ul style="margin-bottom: 65px;">
<h3>
<li style="color: palevioletred;">Home</li>
<hr style="background-color: rgb(80, 60, 60); width: 80px;height: 1px;margin-top: 0px; margin-bottom: 30px;">
<li style="color: pink; text-shadow: 2px 2px 5px" > REGISTRATION</li>
<li style="color: pink; text-shadow: 2px 2px 5px" >SPECIALIZATION </li>
<li style="color: pink; text-shadow: 2px 2px 5px" >PROCEDURES</li>
<li style="color: pink; text-shadow: 2px 2px 5px" > LOCATION</li>
</h3>
</ul>
</th>
<th>
<ul style="margin-bottom: 65px; ">
<h3>
<li style="color: palevioletred;">Email</li>
<hr style="background-color: rgb(80, 60, 60); width: 90px;height: 1px;margin-top: 0px; margin-bottom: 30px;">
<li ><a href="mailto:[email protected]"style="color: pink; text-shadow: 2px 2px 5px" >ANAYA</a></li>
<li ><a href="mailto:[email protected]"style="color: pink; text-shadow: 2px 2px 5px" >MUKUL</a></li>
<li ><a href="mailto:[email protected]"style="color: pink; text-shadow: 2px 2px 5px " >HARSH</a></li>
<li ><a href="mailto:[email protected]"style="color: pink; text-shadow: 2px 2px 5px">ANKIT</a></li>
</h3>
</ul>
</th>
<th>
<ul style="margin-bottom: -110px;">
<h3>
<li style="color: palevioletred;" >Follow us</li>
<hr style="background-color: rgb(80, 60, 60); width: 80px;height: 1px;margin-top: 0px; margin-bottom: 30px;">
<li><a href="https://www.facebook.com/"><img src="facebook.jpeg" alt=""></a></li>
<li><a href="https://www.linkedin.com/" ><img src="linkedin.jpeg" alt=""></a></li>
<li><a href="https://www.instagram.com/"><img src="insta.jpeg" alt=""></a></li>
<li><a href="https://www.twitter.com/"><img src="twitter.jpeg" alt=""></a></li>
<li><a href="https://www.youtube.com/"><img src="youtube.jpeg" alt=""></a></li>
</h3>
</ul>
</th>
</table>
<br><br><br><br>
<hr align="right" style="background-color: rgb(80, 60, 60);">
<p style="color: white; text-align: center; margin-bottom: 5px;" >
<img style="margin-bottom: -5px;" src="phone.jpg" alt="" > +91 96366 20000 / 01 <br><br>
<img style="margin-bottom: -8px;" src="message.jpg" alt=""> [email protected]
</p>
<p style="color: white; text-align: center;"> © Copyright 2021 Life Matters Hospital. All Right Reserved Designed and Developed by Life Matters Hospital</p>
</div>
</body>
</html>