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<?php session_start();
require_once('dbconnection.php');
//Code for Registration
if(isset($_POST['signup']))
{
$Password=$_POST['Password'];
$Confirmpassword=$_POST['Confirmpassword'];
$OrganizationPhonenumber=$_POST['OrganizationPhonenumber'];
$AlternativeMobilenumber=$_POST['AlternativeMobilenumber'];
$Applicationtype=$_POST['Applicationtype'];
$Bedstrength=$_POST['Bedstrength'];
$LocationofHospital=$_POST['LocationofHospital'];
$Website=$_POST['Website'];
$State=$_POST['State'];
$district=$_POST['district'];
$locality=$_POST['locality'];
$block=$_POST['block'];
$Street=$_POST['Street'];
$splitlocation=$_POST['splitlocation'];
$otState=$_POST['otState'];
$otdistrict=$_POST['otdistrict'];
$otlocality=$_POST['otlocality'];
$otblock=$_POST['otblock'];
$otStreet=$_POST['otStreet'];
$Headpersonname=$_POST['Headpersonname'];
$Headctnumber=$_POST['Headctnumber'];
$msg=mysqli_query($con,"insert into hco(Password,Confirmpassword,OrganizationPhonenumber,AlternativeMobilenumber,Applicationtype,Bedstrength,LocationofHospital,Website,State,district,locality,block,Street,splitlocation,otState,otdistrict,otlocality,otblock,otStreet,Headpersonname,Headctnumber) values('$Password','$Confirmpassword','$OrganizationPhonenumber','$AlternativeMobilenumber','$Applicationtype','$Bedstrength','$Website','$LocationofHospital','$splitlocation','$addressofotherlocation','$Headpersonname','$Headctnumber')");
if($msg)
{
echo "<script>alert('Register successfully');</script>";
}
}
?>
<!DOCTYPE html>
<html>
<head>
<title>Account registration form</title>
<link href='https://fonts.googleapis.com/css?family=Open+Sans:400,300,300italic,400italic,600' rel='stylesheet' type='text/css'>
<link href="https://fonts.googleapis.com/css?family=Roboto:300,400,500,700" rel="stylesheet">
<link rel="stylesheet" href="https://www.w3schools.com/w3css/4/w3.css">
<Script>
function myFunction() {
var checkBox = document.getElementById("myCheck");
var text = document.getElementById("text");
if (checkBox.checked == true){
text.style.display = "block";
} else {
text.style.display = "none";
}
}
</script>
<style>
html, body {
min-height: 100%;
}
body, div, form, input, select, p {
padding: 0;
margin: 0;
outline: none;
font-family: Roboto, Arial, sans-serif;
font-size: 13px;
color: #666;
line-height: 22px;
}
h1 {
margin: 0;
font-weight: 400;
}
h3 {
margin: 12px 0;
color: #095484;
}
h4 {
margin: 11px 0;
color: #095484;
}
.main-block {
display: flex;
justify-content: center;
align-items: center;
background: #fff;
}
form {
width: 100%;
padding: 20px;
border-radius: 6px;
background: #fff;
box-shadow: 0 0 20px 0 #095484;
}
fieldset {
border: none;
border-top: 1px solid #095484;
}
.account-details, .personal-details {
display: flex;
flex-wrap: wrap;
justify-content: space-between;
}
.account-details >div, .personal-details >div >div {
display:block;
padding-bottom:5px;
}
.account-details >div, .personal-details >div, input, label {
width: 100%;
}
label {
padding: 0 5px;
text-align: right;
vertical-align: middle;
}
input {
padding: 5px;
vertical-align: middle;
}
.checkbox {
margin-bottom: 10px;
}
select, .children, .gender, .bdate-block {
width: calc(100% + 26px);
padding: 5px 0;
}
select {
background: transparent;
}
.gender input {
width: auto;
}
.gender label {
padding: 0 5px 0 0;
}
.bdate-block {
display: flex;
justify-content: space-between;
}
.birthdate select.day {
width: 35px;
}
.birthdate select.mounth {
width: calc(100% - 94px);
}
.birthdate input {
width: 38px;
vertical-align: unset;
}
.checkbox input, .children input {
width: auto;
margin: -2px 10px 0 0;
}
.checkbox a {
color: #095484;
}
.checkbox a:hover {
color: #095484;
}
button {
width: 100%;
padding: 10px 0;
margin: 10px auto;
border-radius: 5px;
border: none;
background: #095484;
font-size: 14px;
font-weight: 600;
color: #fff;
}
button:hover {
background: #095484;
}
@media (min-width: 568px) {
.account-details >div, .personal-details >div {
width: 50%;
}
input {
margin-bottom: 10px;
border: 1px solid #ccc;
border-radius: 3px;
}
input {
width: calc(100% - 10px);
padding: 5px;
}
select, .children, .gender, .bdate-block {
width: calc(60% + 16px);
}
}
</style>
</head>
<body>
<?php include 'menu.php';?>
<div class="content">
<div class="main-block">
<form name="signup" method="post" >
<fieldset>
<legend>
<h3>Login - Application form</h3>
</legend>
<div class="account-details">
<div><label>Hospital name *</label><input type="text" value="New Hospital" name="name" readonly></div>
<div><label>Email ID*</label><input type="text" value="Test@gmail.com" name="name" readonly></div>
<div><label>Mobile number*</label><input type="text" value="9565163578" name="name" readonly></div>
<div><label>Change password*</label><input type="password" name="Password" placeholder="Change Password" required></div>
<div><label>Confirm password*</label><input type="password" name="Confirmpassword" placeholder="Confirm Password" required></div>
</div>
</fieldset>
<fieldset>
<legend>
<h3>Organization Details</h3>
</legend>
<div class="account-details">
<div><label>Organization Phone number*</label><input type="text" placeholder="Organization Phone number" name="OrganizationPhonenumber" required></div>
<div><label>Alternative Mobile number*</label><input type="text" placeholder="Alternative Mobile number" name="AlternativeMobilenumber" required></div>
<div>
<label> Application type *</label>
<select name="Applicationtype">
<option value="" disabled selected>Application type</option>
<option value="SHCO">SHCO</option>
<option value="HCO">HCO</option>
<option value="DAYCARE">DAYCARE</option>
</select>
</div>
<div><label>Bed strength </label><input type="text" placeholder="Bed strength (currently in operation)" name="Bedstrength"></div>
<div>
<label>Location of Hospital *</label>
<div class="gender">
<input type="radio" value="Urban" id="male" name="LocationofHospital" required/>
<label for="male" class="radio">Urban</label>
<input type="radio" value="Rural" id="female" name="LocationofHospital" required/>
<label for="female" class="radio">Rural</label>
</div>
</div>
<div><label>Website</label><input type="text" placeholder="Website" name="Website"></div>
</div>
</fieldset>
<fieldset>
<legend>
<h4>Address</h4>
</legend>
<div class="account-details">
<div><label>State</label><input type="text" placeholder="State" name="State"></div>
<div><label>District</label><input type="text" placeholder="District" name="district"></div>
<div><label>Block/tahsil *</label><input type="text" placeholder="Block/tahsil" name="block" required></div>
<div><label>Locality</label><input type="text" placeholder="Locality" name="locality"></div>
<div><label>Street *</label><input type="text" placeholder="Street" name="Street" required></div>
</div>
<div>
<div class="checkbox">
<input type="checkbox" name="splitlocation" id="myCheck" onclick="myFunction()" name="checkbox"><span>Does the hospital have split location </span>
</div>
<div id="text" style="display:none">
<div class="account-details">
<div><label>State</label><input type="text" placeholder="State" name="otState"></div>
<div><label>District</label><input type="text" placeholder="District" name="otdistrict"></div>
<div><label>Locality</label><input type="text" placeholder="Locality" name="otlocality"></div>
<div><label>Block/tahsil *</label><input type="text" placeholder="Block/tahsil" name="otblock"></div>
<div><label>Street </label><input type="text" placeholder="Street" name="otStreet" ></div>
</fieldset>
<fieldset>
<legend>
<h4>Head Person Details</h4>
</legend>
<div class="account-details">
<div><label>Head person name*</label><input type="text" placeholder="Head person name" name="Headpersonname"></div>
<div><label>Head person contact No</label><input type="text" name="Headctnumber" placeholder="Head person contact number"></div>
</div>
</fieldset>
<fieldset>
<legend>
<h3>Terms and Mailing</h3>
</legend>
<div class="terms-mailing">
<div class="checkbox">
<input type="checkbox" name="checkbox"><span>I accept the <a href="https://www.w3docs.com/privacy-policy">Privacy Policy for W3Docs.</a></span>
</div>
<div class="checkbox">
<input type="checkbox" name="checkbox"><span>I want to recelve personallzed offers by your site</span>
</div>
</fieldset>
<button type="submit" href="/">Submit</button>
</form>
</div>
</div>
</div>
</html>