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<?php // session_start(); // require_once("../dbconnection.php"); // require_once('../DBManager.php'); // require_once('../LoginManager.php'); // $DisplayForm=True; // $duty= "SELECT * FROM `dutydr` WHERE `AadhaarNumber`='$_GET[AadhaarNumber]'"; // $qduty = mysqli_query($con,$duty); // if($rh = mysqli_fetch_array($qduty)) // { // $DisplayForm=False; // echo "<script>window.location='BasicProfile.php'</script>"; // } // if($DisplayForm) // { ?> <?php session_start(); require_once('../LoginManager.php'); require_once('../DBManager.php'); include('menu.php'); include('header.php'); include("dbconnection.php"); // RMO if(isset($_POST['AddRMO'])){ $updated_at=date("F d, Y / h:i:s A"); $RMO=$con->query("UPDATE `dutydr` SET `FathersName`='$_POST[FathersName]',`Gender`='$_POST[Gender]',`EmailId`='$_POST[EmailId]',`DOB`='$_POST[DOB]',`BloodGroup`='$_POST[BloodGroup]',`Nationality`='$_POST[Nationality]',`MaritalStatus`='$_POST[MaritalStatus]',`Religion`='$_POST[Religion]',`AadhaarNumber`='$_POST[AadhaarNumber]',`Country`='$_POST[Country]',`State`='$_POST[State]',`Distict`='$_POST[Distict]',`PinCode`='$_POST[PinCode]',`Address`='$_POST[Address]' WHERE `rmoid`='$_POST[rmoid]'"); //echo $RMO; if($RMO){ echo "<script>alert('RMO Update successfully');</script><script>window.location='ProfessionalProfile.php?userno=$_POST[rmoid]'</script>;</script>"; } } // Nurse if(isset($_POST['AddNurse'])){ foreach($_FILES["Upload_Nurse"]["name"] as $key=>$val) { $info=getimagesize($_FILES['Upload_Nurse']['tmp_name'][$key]); if(isset($info['mime'])){ if($info['mime']=="image/jpeg"){ $img=imagecreatefromjpeg($_FILES['Upload_Nurse']['tmp_name'][$key]); } elseif($info['mime']=="image/png"){ $img=imagecreatefrompng($_FILES['Upload_Nurse']['tmp_name'][$key]); } elseif($info['mime']=="image/gif"){ $img=imagecreatefromgif($_FILES['Upload_Nurse']['tmp_name'][$key]); } elseif($info['mime']=="image/jpg"){ $img=imagecreatefromjpg($_FILES['Upload_Nurse']['tmp_name'][$key]); } else{ echo "Only select jpg or png image"; } if(isset($img)){ $newFileName=$user_id.$email.$filename.$count.'.jpg'; $file = $newFileName.'_'.$val; imagejpeg($img, "uploads/$file" ,20); $updated_at=date("F d, Y / h:i:s A"); $nurse=$con->query("UPDATE `nurse` SET photo='$file', `FathersName`='$_POST[NurseFathersName]',`Gender`='$_POST[NurseGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[NurseDOB]',`BloodGroup`='$_POST[NurseBloodGroup]',`Nationality`='$_POST[NurseNationality]',`MaritalStatus`='$_POST[NurseMaritalStatus]',`Religion`='$_POST[NurseReligion]',`AadhaarNumber`='$_POST[NurseAadhaarNumber]',`Country`='$_POST[NurseCountry]',`State`='$_POST[NurseState]',`Distict`='$_POST[NurseDistict]',`PinCode`='$_POST[NursePinCode]',`Address`='$_POST[NurseAddress]' WHERE `Nurseid`='$_POST[Nurseid]'"); //echo $nurse; if($nurse){ echo "<script>alert('Nurse Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[Nurseid]'</script>"; } } } } } // Front Office if(isset($_POST['AddFront'])){ foreach($_FILES["Upload_Consent"]["name"] as $key=>$val) { $info=getimagesize($_FILES['Upload_Consent']['tmp_name'][$key]); if(isset($info['mime'])){ if($info['mime']=="image/jpeg"){ $img=imagecreatefromjpeg($_FILES['Upload_Consent']['tmp_name'][$key]); } elseif($info['mime']=="image/png"){ $img=imagecreatefrompng($_FILES['Upload_Consent']['tmp_name'][$key]); } elseif($info['mime']=="image/gif"){ $img=imagecreatefromgif($_FILES['Upload_Consent']['tmp_name'][$key]); } elseif($info['mime']=="image/jpg"){ $img=imagecreatefromjpg($_FILES['Upload_Consent']['tmp_name'][$key]); } else{ echo "Only select jpg or png image"; } if(isset($img)){ $newFileName=$user_id.$email.$filename.$count.'.jpg'; $file = $newFileName.'_'.$val; imagejpeg($img, "uploads/$file" ,20); $updated_at=date("F d, Y / h:i:s A"); $front=$con->query("UPDATE `front` SET `photo`='$file', `FathersName`='$_POST[FrontFathersName]',`Gender`='$_POST[FrontGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[FrontDOB]',`BloodGroup`='$_POST[FrontBloodGroup]',`Nationality`='$_POST[FrontNationality]',`MaritalStatus`='$_POST[FrontMaritalStatus]',`Religion`='$_POST[FrontReligion]',`AadhaarNumber`='$_POST[FrontAadhaarNumber]',`Country`='$_POST[FrontCountry]',`State`='$_POST[FrontState]',`Distict`='$_POST[FrontDistict]',`PinCode`='$_POST[FrontPinCode]',`Address`='$_POST[FrontAddress]' WHERE `frid`='$_POST[frid]'"); echo $front; if($front){ echo "<script>alert('Front Office Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[frid]'</script>"; } } } } } // HR if(isset($_POST['AddHR'])){ $updated_at=date("F d, Y / h:i:s A"); $HR=$con->query("UPDATE `hr` SET `FathersName`='$_POST[HRFathersName]',`Gender`='$_POST[HRGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[HRDOB]',`BloodGroup`='$_POST[HRBloodGroup]',`Nationality`='$_POST[HRNationality]',`MaritalStatus`='$_POST[HRMaritalStatus]',`Religion`='$_POST[HRReligion]',`AadhaarNumber`='$_POST[HRAadhaarNumber]',`Country`='$_POST[HRCountry]',`State`='$_POST[HRState]',`Distict`='$_POST[HRDistict]',`PinCode`='$_POST[HRPinCode]',`Address`='$_POST[HRAddress]' WHERE `hrid`='$_POST[hrid]'"); echo $HR; if($HR){ echo "<script>alert('Human resources Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[hrid]'</script>"; } } //OT if(isset($_POST['AddOT'])){ $updated_at=date("F d, Y / h:i:s A"); $OT=$con->query("UPDATE `ot` SET `FathersName`='$_POST[OTFathersName]',`Gender`='$_POST[OTGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[OTDOB]',`BloodGroup`='$_POST[OTBloodGroup]',`Nationality`='$_POST[OTNationality]',`MaritalStatus`='$_POST[OTMaritalStatus]',`Religion`='$_POST[OTReligion]',`AadhaarNumber`='$_POST[OTAadhaarNumber]',`Country`='$_POST[OTCountry]',`State`='$_POST[OTState]',`Distict`='$_POST[OTDistict]',`PinCode`='$_POST[OTPinCode]',`Address`='$_POST[OTAddress]' WHERE `otid`='$_POST[otid]'"); echo $OT; if($OT){ echo "<script>alert('OT Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[otid]'</script>"; } } //Lab if(isset($_POST['AddLab'])){ $updated_at=date("F d, Y / h:i:s A"); $Lab=$con->query("UPDATE `addlab` SET `FathersName`='$_POST[LabFathersName]',`Gender`='$_POST[LabGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[LabDOB]',`BloodGroup`='$_POST[LabBloodGroup]',`Nationality`='$_POST[LabNationality]',`MaritalStatus`='$_POST[LabMaritalStatus]',`Religion`='$_POST[LabReligion]',`AadhaarNumber`='$_POST[LabAadhaarNumber]',`Country`='$_POST[LabCountry]',`State`='$_POST[LabState]',`Distict`='$_POST[LabDistict]',`PinCode`='$_POST[LabPinCode]',`Address`='$_POST[LabAddress]' WHERE `labid`='$_POST[labid]'"); echo $Lab; if($Lab){ echo "<script>alert('Lab Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[labid]'</script>"; } } //Diagnostic if(isset($_POST['AddDiagnostic'])){ foreach($_FILES["Upload_Diagnostic"]["name"] as $key=>$val) { $info=getimagesize($_FILES['Upload_Diagnostic']['tmp_name'][$key]); if(isset($info['mime'])){ if($info['mime']=="image/jpeg"){ $img=imagecreatefromjpeg($_FILES['Upload_Diagnostic']['tmp_name'][$key]); } elseif($info['mime']=="image/png"){ $img=imagecreatefrompng($_FILES['Upload_Diagnostic']['tmp_name'][$key]); } elseif($info['mime']=="image/gif"){ $img=imagecreatefromgif($_FILES['Upload_Diagnostic']['tmp_name'][$key]); } elseif($info['mime']=="image/jpg"){ $img=imagecreatefromjpg($_FILES['Upload_Diagnostic']['tmp_name'][$key]); } else{ echo "Only select jpg or png image"; } if(isset($img)){ $newFileName=$user_id.$email.$filename.$count.'.jpg'; $file = $newFileName.'_'.$val; imagejpeg($img, "uploads/$file" ,20); $updated_at=date("F d, Y / h:i:s A"); $Diagnostic=$con->query("UPDATE `adddigno` SET `photo`='$file', `FathersName`='$_POST[DiagnosticFathersName]',`Gender`='$_POST[DiagnosticGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[DiagnosticDOB]',`BloodGroup`='$_POST[DiagnosticBloodGroup]',`Nationality`='$_POST[DiagnosticNationality]',`MaritalStatus`='$_POST[DiagnosticMaritalStatus]',`Religion`='$_POST[DiagnosticReligion]',`AadhaarNumber`='$_POST[DiagnosticAadhaarNumber]',`Country`='$_POST[DiagnosticCountry]',`State`='$_POST[DiagnosticState]',`Distict`='$_POST[DiagnosticDistict]',`PinCode`='$_POST[DiagnosticPinCode]',`Address`='$_POST[DiagnosticAddress]' WHERE `dignoid`='$_POST[dignoid]'"); echo $Diagnostic; if($Diagnostic){ echo "<script>alert('Diagnostic Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[dignoid]'</script>"; } } }}} if(isset($_POST['AddOptomatrix'])){ foreach($_FILES["Upload_Optomatrix"]["name"] as $key=>$val) { $info=getimagesize($_FILES['Upload_Optomatrix']['tmp_name'][$key]); if(isset($info['mime'])){ if($info['mime']=="image/jpeg"){ $img=imagecreatefromjpeg($_FILES['Upload_Optomatrix']['tmp_name'][$key]); } elseif($info['mime']=="image/png"){ $img=imagecreatefrompng($_FILES['Upload_Optomatrix']['tmp_name'][$key]); } elseif($info['mime']=="image/gif"){ $img=imagecreatefromgif($_FILES['Upload_Optomatrix']['tmp_name'][$key]); } elseif($info['mime']=="image/jpg"){ $img=imagecreatefromjpg($_FILES['Upload_Optomatrix']['tmp_name'][$key]); } else{ echo "Only select jpg or png image"; } if(isset($img)){ $newFileName=$user_id.$email.$filename.$count.'.jpg'; $file = $newFileName.'_'.$val; imagejpeg($img, "uploads/$file" ,20); $updated_at=date("F d, Y / h:i:s A"); $Optomatrix=$con->query("UPDATE `optomatrix` SET `photo`='$file', `FathersName`='$_POST[OptomatrixFathersName]',`Gender`='$_POST[OptomatrixGender]',`EmailId`='$_POST[userid]',`DOB`='$_POST[OptomatrixDOB]',`BloodGroup`='$_POST[OptomatrixBloodGroup]',`Nationality`='$_POST[OptomatrixNationality]',`MaritalStatus`='$_POST[OptomatrixMaritalStatus]',`Religion`='$_POST[OptomatrixReligion]',`AadhaarNumber`='$_POST[OptomatrixAadhaarNumber]',`Country`='$_POST[OptomatrixCountry]',`State`='$_POST[OptomatrixState]',`Distict`='$_POST[OptomatrixDistict]',`PinCode`='$_POST[OptomatrixPinCode]',`Address`='$_POST[OptomatrixAddress]' WHERE `OptomatrixId`='38232'"); echo $Optomatrix; if($Optomatrix){ echo "<script>alert('Optomatrix Update successfully');</script>"; echo " <script>window.location='ProfessionalProfile.php?userno=$_POST[Optomatrixid]'</script>"; } } }}} ?> <!DOCTYPE html> <html lang="en"> <script src="https://code.jquery.com/jquery-2.1.1.min.js" type="text/javascript"></script> <script> function checkAvailability() { $("#loaderIcon").show(); jQuery.ajax({ url: "rmo_check.php", data:'uname='+$("#userid").val(), type: "POST", success:function(data){ $("#user-availability-status").html(data); $("#loaderIcon").hide(); }, error:function (){} }); } </script> <script> function isNumber(evt) { evt = (evt) ? evt : window.event; var charCode = (evt.which) ? evt.which : evt.keyCode; if (charCode > 31 && (charCode < 48 || charCode > 57)) { alert("Please enter only Numbers."); return false; } return true; } function ValidateNo() { var phoneNo = document.getElementById('numbers'); if (phoneNo.value == "" || phoneNo.value == null) { alert("Please enter your Mobile No."); return false; } if (phoneNo.value.length < 10 || phoneNo.value.length > 10) { alert("Mobile No. is not valid, Please Enter 10 Digit Mobile No."); return false; } return true; } </script> <script src=" https://cdn.jsdelivr.net/npm/sweetalert2@11.10.0/dist/sweetalert2.all.min.js "></script> <link href=" https://cdn.jsdelivr.net/npm/sweetalert2@11.10.0/dist/sweetalert2.min.css " rel="stylesheet"> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.1.1/jquery.min.js"></script> <script type="text/javascript"> $(document).ready(function(){ $('#myForm').submit(function() { $('#loaderImg').show(); return true; }); }); </script> <style> #loaderImg { position: absolute; top: 0; bottom: 0; left: 0; right: 0; margin: auto; border: 10px solid grey; border-radius: 50%; border-top: 10px solid black; width: 100px; height: 100px; animation: spin 1s linear infinite; z-index:1000000000; } @keyframes spin { 0% { -webkit-transform: rotate(0deg); transform: rotate(0deg); } 100% { -webkit-transform: rotate(360deg); transform: rotate(360deg); } } </style> <meta http-equiv="content-type" content="text/html;charset=UTF-8" /> <title> Pt Signup</title> <meta charset="UTF-8"> <meta name="viewport" content="width=device-width, initial-scale=1"> <link rel="stylesheet" href="new2.css"> </head> <body> <div class="content-wrapper"> <section class="content-header"> <!-- Page Preloder --> <?php session_start(); require_once('../DBManager.php'); require_once('../LoginManager.php'); include("dbconnection.php"); $narayan=LoginManager::currentUser(); $harilal=LoginManager::getUserTypeByuname("$narayan"); $sql ="SELECT * FROM site_users WHERE userno='$harilal'"; $qsql = mysqli_query($con,$sql); $re = mysqli_fetch_array($qsql); if($re['usertype']=='RMO'){ $rmo=$con->query("SELECT * FROM `dutydr` WHERE rmoid='".$re['userno']."'"); } if($re['usertype']=='Nurse'){ $rmo=$con->query("SELECT * FROM `nurse` WHERE Nurseid='".$re['userno']."'"); } if($re['usertype']=='FrontOffice'){ $rmo=$con->query("SELECT * FROM `front` WHERE frid='".$re['userno']."'"); } if($re['usertype']=='HR'){ $rmo=$con->query("SELECT * FROM `hr` WHERE hrid='".$re['userno']."'"); } if($re['usertype']=='OT'){ $rmo=$con->query("SELECT * FROM `ot` WHERE otid='".$re['userno']."'"); } if($re['usertype']=='Lab'){ $rmo=$con->query("SELECT * FROM `addlab` WHERE labid='".$re['userno']."'"); } if($re['usertype']=='Diagnostic'){ $rmo=$con->query("SELECT * FROM `adddigno` WHERE dignoid='".$re['userno']."'"); } if($re['usertype']=='Optometrist'){ $rmo=$con->query("SELECT * FROM `optomatrix` WHERE OptomatrixId='".$re['userno']."'"); } $RowRMO=$rmo->fetch_assoc(); ?> <div style = "display:none;" id = "loaderImg"> <div class="loader"> </div> </div> <?php if($re['usertype']=='RMO'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['Name']; ?>" readonly /> <input type="hidden" name="rmoid" value="<?php echo $RowRMO['rmoid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $re['uname']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="FathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="Gender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="Gender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="Gender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="DOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="BloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="Nationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="MaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="Religion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Christian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="AadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="Country" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="State" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="Distict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="PinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="Address" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Profile Picture:</label> <input name="Upload_RMO[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddRMO"> </form> <?php } ?> <?php if($re['usertype']=='Nurse'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['uname']; ?>" readonly /> <input type="hidden" name="Nurseid" value="<?php echo $RowRMO['Nurseid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="NurseFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="NurseGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="NurseGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="NurseGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="NurseDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="NurseBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="NurseNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="NurseMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="NurseReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Christian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="NurseAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="NurseCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="NurseState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="NurseDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="NursePinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="NurseAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_Nurse[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddNurse"> </form> <?php } ?> <?php if($re['usertype']=='FrontOffice'){ ?> <form id="myForm" method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['Name']; ?>" readonly /> <input type="hidden" name="frid" value="<?php echo $RowRMO['frid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="FrontFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="FrontGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="FrontGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="FrontGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="FrontDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="FrontBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="FrontNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="FrontMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="FrontReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Christian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="FrontAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="FrontCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="FrontState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="FrontDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="FrontPinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="FrontAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_Consent[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddFront"> </form> <?php } ?> <?php if($re['usertype']=='HR'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['Name']; ?>" readonly /> <input type="hidden" name="hrid" value="<?php echo $RowRMO['hrid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="HRFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="HRGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="HRGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="HRGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="HRDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="HRBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="HRNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="HRMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="HRReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Christian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="HRAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="HRCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="HRState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="HRDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="HRPinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="HRAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_HR[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddHR"> </form> <?php } ?> <?php if($re['usertype']=='OT'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['Name']; ?>" readonly /> <input type="hidden" name="otid" value="<?php echo $RowRMO['otid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="OTFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="OTGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="OTGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="OTGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="OTDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="OTBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="OTNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="OTMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="OTReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Cistian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="OTAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="OTCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="OTState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="OTDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="OTPinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="OTAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_OT[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddOT"> </form> <?php } ?> <?php if($re['usertype']=='Lab'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['Name']; ?>" readonly /> <input type="hidden" name="labid" value="<?php echo $RowRMO['labid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="LabFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="LabGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="LabGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="LabGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="LabDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="LabBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="LabNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="LabMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="LabReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Cistian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="LabAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="LabCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="LabState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="LabDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="LabPinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="LabAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_Lab[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddLab"> </form> <?php } ?> <?php if($re['usertype']=='Diagnostic'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['Name']; ?>" readonly /> <input type="hidden" name="dignoid" value="<?php echo $RowRMO['dignoid']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="DiagnosticFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="DiagnosticGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="DiagnosticGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="DiagnosticGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="DiagnosticDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="DiagnosticBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="DiagnosticNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="DiagnosticMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="DiagnosticReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Cistian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="DiagnosticAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="DiagnosticCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="DiagnosticState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="DiagnosticDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="DiagnosticPinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="DiagnosticAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_Diagnostic[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddDiagnostic"> </form> <?php } ?> <?php if($re['usertype']=='Optometrist'){ ?> <form method="post" enctype="multipart/form-data"> <h3><i class="fa fa-angle-right"></i> Basic Profile </h3> <div class="row"> <div class="col-sm-12"> <div id="frmCheckUsername"></div></div> <div class='col-sm-6'> <label for="item"> Name <span>*</span></label> <input class="input100" type="text" name="Name" placeholder="Enter your Name" value="<?php echo $RowRMO['uname']; ?>" readonly /> <input type="text" name="Optomatrixid" value="<?php echo $RowRMO['OptomatrixId']; ?>" /> </div> <div class='col-sm-6'><label for="item"> Email id<span>*</span></label> <input class="input100" type="email" name="userid" value="<?php echo $RowRMO['user_id']; ?>" readonly /> </div> <div class='col-sm-6'><label for="item"> Mobile Number<span>*</span></label> <input type="text" name="numbers" id="numbers" value="<?php echo $RowRMO['numbers']; ?>" readonly /></div> <div class='col-sm-6'><label for="item"> Fathers Name<span>*</span></label> <input type="text" name="OptomatrixFathersName" id="FathersName" required placeholder="Father's Name" value="<?php echo $RowRMO['FathersName']; ?>"/></div> <div class='col-sm-6'><label for="item"> Gender<span>*</span></label> <div class="checkbox"><input onclick="ValidateNo();" type="radio" name="OptomatrixGender" value="Male" required <?php echo ($RowRMO['Gender']=='Male')?'checked':'' ?>> <span>Male </span></div><div class="checkbox"> <input type="radio" onclick="ValidateNo();" name="OptomatrixGender" value="Female" <?php echo ($RowRMO['Gender']=='Female')?'checked':'' ?>> <span>Female </span></div><div class="checkbox"><input type="radio" onclick="ValidateNo();" name="OptomatrixGender" value="Other" <?php echo ($RowRMO['Gender']=='Other')?'checked':'' ?>> <span>Other </span></div> </div> <div class='col-sm-6'><label for="item"> DOB<span>*</span></label> <input type="date" name="OptomatrixDOB" id="DOB" placeholder="DOB" required value="<?php echo $RowRMO['DOB']; ?>"/></div> <div class='col-sm-6'><label for="item"> Blood Group<span>*</span></label> <select name="OptomatrixBloodGroup" class="form-control" > <option value="">Blood Group</option> <option value='A+' <?php echo ($RowRMO['BloodGroup']=='A+')?'selected':'' ?>>A+</option> <option value='A-' <?php echo ($RowRMO['BloodGroup']=='A-')?'selected':'' ?>>A-</option> <option value='B+' <?php echo ($RowRMO['BloodGroup']=='B+')?'selected':'' ?>>B+</option> <option value='B-' <?php echo ($RowRMO['BloodGroup']=='B-')?'selected':'' ?>>B-</option> <option value='O+' <?php echo ($RowRMO['BloodGroup']=='O+')?'selected':'' ?>>O+</option> <option value='O-' <?php echo ($RowRMO['BloodGroup']=='O-')?'selected':'' ?>>O-</option> <option value='AB+' <?php echo ($RowRMO['BloodGroup']=='AB+')?'selected':'' ?>>AB+</option> <option value='AB-' <?php echo ($RowRMO['BloodGroup']=='AB-')?'selected':'' ?>>AB-</option> </select> </div> <div class='col-sm-6'><label for="item"> Nationality<span>*</span></label> <select name="OptomatrixNationality" class="form-control"> <option value="0">Nationality</option> <option value="Indian" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Indian')?'selected':'' ?>>Indian</option> <option value="Nepali" style="color:#004F00" <?php echo ($RowRMO['Nationality']=='Nepali')?'selected':'' ?>>Nepali</option> </select> </div> <div class='col-sm-6'><label for="item"> Marital Status<span>*</span></label> <select name="OptomatrixMaritalStatus" class="form-control"> <option value="" disabled selected>Marital status </option> <option value="Single" label="Single" <?php echo ($RowRMO['MaritalStatus']=='Single')?'selected':'' ?>>Single</option> <option value="Married" label="Married" <?php echo ($RowRMO['MaritalStatus']=='Married')?'selected':'' ?>>Married</option> <option value="Widowed" <?php echo ($RowRMO['MaritalStatus']=='Widowed')?'selected':'' ?>>Widowed</option> <option value="divorced" label="divorced" <?php echo ($RowRMO['MaritalStatus']=='divorced')?'selected':'' ?>>Divorced</option> </select> </div> <div class='col-sm-6'><label for="item"> Religion<span>*</span></label> <select name="OptomatrixReligion" class="form-control" > <option value="" disabled selected>Religion </option> <option value="Hindu" label="Hindu" <?php echo ($RowRMO['Religion']=='Hindu')?'selected':'' ?>>Hindu</option> <option value="Muslim" label="Muslim" <?php echo ($RowRMO['Religion']=='Muslim')?'selected':'' ?>>Muslim</option> <option value="Christian" label="Christian" <?php echo ($RowRMO['Religion']=='Christian')?'selected':'' ?>>Christian</option> <option value="Sikh" label="Sikh" <?php echo ($RowRMO['Religion']=='Sikh')?'selected':'' ?>>Sikh</option> <option value="Parsi" label="Parsi" <?php echo ($RowRMO['Religion']=='Parsi')?'selected':'' ?>>Parsi</option> <option value="Jain" label="Jain" <?php echo ($RowRMO['Religion']=='Jain')?'selected':'' ?>>Jain</option> <option value="Buddhist" label="Buddhist" <?php echo ($RowRMO['Religion']=='Buddhist')?'selected':'' ?>>Buddhist</option> <option value="Jewish" label="Jewish" <?php echo ($RowRMO['Religion']=='Jewish')?'selected':'' ?>>Jewish</option> <option value="No Religion" label="No Religion" <?php echo ($RowRMO['Religion']=='No Religion')?'selected':'' ?>>No Religion</option> <option value="Spiritual - not religious" label="Spiritual" <?php echo ($RowRMO['Religion']=='Spiritual - not religious')?'selected':'' ?>>Spiritual</option> <option value="Other" label="Other" <?php echo ($RowRMO['Religion']=='Other')?'selected':'' ?>>Other</option> </select> </div> <div class='col-sm-6'><label for="item"> Aadhaar Number<span>*</span></label> <input type="text" name="OptomatrixAadhaarNumber" id="AadhaarNumber" placeholder="Aadhaar Number" required value="<?php echo $RowRMO['AadhaarNumber']; ?>"/></div> <div class='col-sm-6'><label for="item"> Country<span>*</span></label> <select class="form-control" name="OptomatrixCountry" id="country" required> <option value="" disabled selected>Country</option> <?php include("dbconnection.php"); $query = "SELECT * FROM countries WHERE status = 1 AND country_name ='India'"; $result = $con->query($query); if($result->num_rows > 0){ while($row = $result->fetch_assoc()){ echo '<option value="'.$row['country_id'].'">'.$row['country_name'].'</option>'; } }else{ echo '<option value="">Country not available</option>'; } ?> </select> </div> <div class='col-sm-6'><label for="item"> State<span>*</span></label> <select class="form-control" name="OptomatrixState" id="state" required> <option value="">Select country first</option> </select> </div> <div class='col-sm-6'><label for="item"> Distict<span>*</span></label> <select class="form-control" name="OptomatrixDistict" id="city" required> <option value="">Select state first</option> </select> </div> <div class='col-sm-6'><label for="item"> PinCode<span>*</span></label> <input type="text" name="OptomatrixPinCode" id="PinCode" required placeholder="PinCode" value="<?php echo $RowRMO['PinCode']; ?>"></div> <div class='col-sm-6'><label for="item"> Address<span>*</span></label> <input type="text" name="OptomatrixAddress" id="Address" required placeholder="Address" value="<?php echo $RowRMO['Address']; ?>"></div> <div class='col-sm-6'><label>Select Image File:</label> <input name="Upload_Optomatrix[]" type="file" multiple></div> </div> <input type="submit" id="clicknow" value="Submit" name="AddOptomatrix"> </form> <?php } ?> </div> </body> <script src="https://ajax.googleapis.com/ajax/libs/jquery/3.7.0/jquery.min.js"></script> <script> $(document).ready(function(){ $('#country').on('change', function(){ var countryID = $(this).val(); if(countryID){ $.ajax({ type:'POST', url:'ajaxData.php', data:'country_id='+countryID, success:function(html){ $('#state').html(html); $('#city').html('<option value="">Select state first</option>'); } }); }else{ $('#state').html('<option value="">Select country first</option>'); $('#city').html('<option value="">Select state first</option>'); } }); $('#state').on('change', function(){ var stateID = $(this).val(); if(stateID){ $.ajax({ type:'POST', url:'ajaxData.php', data:'state_id='+stateID, success:function(html){ $('#city').html(html); } }); }else{ $('#city').html('<option value="">Select state first</option>'); } }); }); $(document).ready(function () { $('select').selectize({ sortField: 'text' }); }); </script> </html> <?php //} ?>