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<?php session_start();
require_once('dbconnection.php');
//Code for Registration
if(isset($_POST['signup']))
{
$password=$_POST['password'];
$Hospitalname=$_POST['Hospitalname'];
$SPOCNAME=$_POST['SPOCNAME'];
$SPOCDESIGNATION=$_POST['SPOCDESIGNATION'];
$EmailID=$_POST['EmailID'];
$Mobilenumber=$_POST['Mobilenumber'];
$Selectstate=$_POST['Selectstate'];
$Selectdistrict=$_POST['Selectdistrict'];
$Pincode=$_POST['Pincode'];
$sanctionedbed=$_POST['sanctionedbed'];
$Hospitalparenttype=$_POST['Hospitalparenttype'];
$Hospitaltype=$_POST['Hospitaltype'];
$Registrationnumber=$_POST['Registrationnumber'];
$Authorityregistered=$_POST['Authorityregistered'];
$myfile=$_POST['myfile'];
$GenerateOTP=$_POST['GenerateOTP'];
$msg=mysqli_query($con,"insert into regi(password,Hospitalname,SPOCNAME,SPOCDESIGNATION,EmailID,Mobilenumber,Selectstate,Selectdistrict,Pincode,sanctionedbed,Hospitalparenttype,Hospitaltype,Registrationnumber,Authorityregistered,myfile,GenerateOTP) values('$password','$Hospitalname','$SPOCNAME','$SPOCDESIGNATION','$EmailID','$Mobilenumber','$Selectstate','$Selectdistrict','$Pincode','$sanctionedbed','$Hospitalparenttype','$Hospitaltype','$Registrationnumber','$Authorityregistered','$myfile','$GenerateOTP')");
if($msg)
{
echo "<script>alert('Register successfully');</script>";
}
}
?>
</script>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Document</title>
<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: 100%;
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;
}
}
}
</style>
</head>
<body>
<?php include 'menu.php';?>
<div class="content">
<div class="main-block">
<form name="signup" method="post" >
<fieldset>
<legend>
<h3>Registration </h3>
</legend>
<div class="account-details">
<div> <label for="item">password<span>*</span></label>
<input id="name" type="text" name="password" placeholder="password" required/>
</div>
<div> <label for="item">Hospital name<span>*</span></label>
<input id="name" type="text" name="Hospitalname" placeholder="Hospital name" required/>
</div>
<div>
<label for="address">SPOC NAME<span>*</span></label>
<input id="address" type="text" name="SPOCNAME" placeholder="SPOC NAME" required/>
</div>
<div>
<label for="address">SPOC DESIGNATION<span>*</span></label>
<input type="text" name="SPOCDESIGNATION" placeholder="SPOC DESIGNATION" />
</div>
<div>
<label for="address">Email ID<span>*</span></label>
<input type="text" name="EmailID" placeholder="Email ID" />
</div>
<div>
<label for="address">Mobile number<span>*</span></label>
<input type="text" name="Mobilenumber" placeholder="Mobile number" />
</div>
<div>
<label for="address">Select state<span>*</span></label>
<select name="Selectstate">
<option value="" disabled selected>Select state</option>
<option value="Varanasi">Uttar Pradesh</option>
</select>
</div>
<div>
<label for="address">Select district<span>*</span></label>
<select name="Selectdistrict">
<option value="" disabled selected>Select district</option>
<option value="Varanasi">Varanasi</option>
<option value="Lucknow">Lucknow</option>
<option value="Jaunpur">Jaunpur</option>
<option value="Agra">Agra</option>
<option value="Gautam Buddh Nagar">Gautam Buddh Nagar</option>
<option value="Prayagraj">Prayagraj</option>
</select>
</div>
<div>
<label for="address">Pin code<span>*</span></label>
<input type="text" name="Pincode" placeholder="Pin code" />
</div>
<div>
<label for="address">Number of sanctioned bed<span>*</span></label>
<input type="text" name="sanctionedbed" placeholder="Number of sanctioned bed" />
</div>
<div>
<label for="address">Hospital parent type<span>*</span></label>
<select class="w3-select w3-border" name="Hospitalparenttype">
<option value="" disabled selected>Hospital parent type </option>
<option value="1">Single</option>
<option value="2">Group</option>
</select>
</div>
<div>
<label for="address">Hospital type <span>*</span></label>
<select class="w3-select w3-border" name="Hospitaltype">
<option value="" disabled selected>Hospital type </option>
<option value="1">Public/private(corporate)</option>
<option value="2">Government</option>
<option value="3">Trust/charitable</option>
<option value="4">Other</option>
</select>
</div>
<div>
<label for="address">Registration number <span>*</span></label>
<input type="text" name="Registrationnumber" placeholder="Registration number " />
</div>
<div>
<label for="address">Authority under which registered<span>*</span></label>
<input type="text" name="Authorityregistered" placeholder="Authority under which registered" />
</div>
<div>
<label for="address">Upload Certificate <span>*</span></label>
<input type="file" name="myfile" placeholder="Upload Certificate " />
</div>
<div>
<label for="address">Authority under which registered<span>*</span></label>
<input type="button" name="GenerateOTP" value="GenerateOTP" />
</div>
</fieldset>
</div>
<fieldset>
<div class="btn-block">
<button type="submit" name="signup">Submit</button>
</div>
</fieldset>
</br>
</form>
</div>
</body>
</html>