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doctor_signup.php
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doctor_signup.php
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<?php include "header.php" ?>
<div class="container">
<form class="well form-horizontal" action="doc_signup_db.php" method="post" role="form" id="contact_form" enctype="multipart/form-data">
<fieldset>
<!-- Form Name -->
<legend><center><h2><b>Registration Form</b></h2></center></legend><br>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label">First Name</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input name="first_name" placeholder="First Name" class="form-control" type="text" required >
</div>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" >Last Name</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-user"></i></span>
<input name="last_name" placeholder="Last Name" class="form-control" type="text" required>
</div>
</div>
</div>
<!-- title/designation -->
<div class="form-group">
<label class="col-md-4 control-label">Title/Designation</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-star"></i></span>
<input name="designation" placeholder="Title/Designation" class="form-control" type="text" required>
</div>
</div>
</div>
<!-- gender -->
<div class="form-group">
<label class="col-md-4 control-label">Gender</label>
<div class="col-md-4 selectContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select name="gender" class="form-control selectpicker" required>
<option>Gender</option>
<option value="m">Male</option>
<option value="f">Female</option>
</select>
</div>
</div>
</div>
<div class="form-group">
<label class="col-md-4 control-label">Your Specialty</label>
<div class="col-md-4 selectContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-list"></i></span>
<select name="specialty" class="form-control selectpicker" required>
<option value="">Specialty</option>
<option value="cardiology">Cardiology</option>
<option value="dermatology">Dermatology</option>
<option value="endocrinology">Endocrinology</option>
<option value="ent">ENT</option>
<option value="general_physician">General Physician</option>
<option value="urology">Urology</option>
<option value="psychiatry">Psychiatry</option>
<option value="pediatrics">Pediatrics</option>
<option value="oncology">Oncology</option>
</select>
</div>
</div>
</div>
<!-- BMDC registration no. -->
<div class="form-group">
<label class="col-md-4 control-label">BMDC Registration No.</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-pencil"></i></span>
<input name="bmdc_reg_no" placeholder="BMDC Registration No." class="form-control" type="text" required>
</div>
</div>
</div>
<!-- hospital name -->
<div class="form-group">
<label class="col-md-4 control-label">Hospital Name</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-pencil"></i></span>
<input name="hospital_name" placeholder="Hospital You work in" class="form-control" type="text" required>
</div>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" >Password</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-eye-close"></i></span>
<input name="password" placeholder="Password" class="form-control" type="password" required >
</div>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label" >Confirm Password</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-eye-close"></i></span>
<input name="password_2" placeholder="Confirm Password" class="form-control" type="password" required >
</div>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label">E-Mail</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-envelope"></i></span>
<input name="email" placeholder="E-Mail Address" class="form-control" type="text" required>
</div>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-4 control-label">Contact No.</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<span class="input-group-addon"><i class="glyphicon glyphicon-earphone"></i></span>
<input name="mobile_no" placeholder="Mobile/Telephone no." class="form-control" type="text" required>
</div>
</div>
</div>
<div class="form-group">
<label class="col-md-4 control-label">Description (Professional Statement)</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<textarea class="form-control" rows="5" id="comment" name="professional_statement" required></textarea>
</div>
</div>
</div>
<!-- profile image -->
<div class="form-group">
<label class="col-md-4 control-label">Upload Image:</label>
<div class="col-md-4 inputGroupContainer">
<div class="input-group">
<input type="file" class="custom-file-input" id="customFile" name="file" />
</div>
</div>
</div>
<!-- Select Basic -->
<!-- Button -->
<div class="form-group">
<label class="col-md-4 control-label"></label>
<div class="col-md-4"><br>
              <button type="submit" name="submit" value="submit" class="btn btn-info" >        SUBMIT <span class="glyphicon glyphicon-send"></span>        </button>
</div>
</div>
</fieldset>
</form>
</div>
<?php include "footer.php" ?>
</div><!-- /.container -->
<!-- <script type="text/javascript" src="doctor_signup.js"></script> -->