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patient.html
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patient.html
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<!DOCTYPE HTML>
<html lang="en-us">
<head>
<meta charset="utf-8">
<title>Patient Form</title>
<script src="validation.js"></script>
<script src = "cities.js"></script>
<link rel="stylesheet" href="donor_form.css">
</head>
<body>
<ul class="top">
<li class="l1"><a href="#"><img src="phonewhite.jpeg" id="logo0"> 7284056951</a></li>
<li class="l1"><a href="#"><img src="emailwhite.png" id="logo1"> [email protected]</a></li>
</ul>
<ul>
<li class="l2"><a href="home.html">Home</a></li>
<li class="l2"><a href="login.html">Login</a></li>
<li class="l2"><a href="main_page.html">Search donor</a></li>
</ul><br>
<form action = "patient_form.php" method = "post">
<label>First Name:</label>
<input type="text" placeholder="*" name = "firstName"></input>
<br><br>
<label>Last Name:</label>
<input type="text" placeholder="*" name = "lastName"></input>
<br><br>
<label>Gender:</label>
<input type="radio" name="gender" value = "male" id = "male">Male</input>
<input type="radio" name="gender" value = "female" id = "female">Female</input>
<input type="radio" name="gender" value = "other" id = "other">Other</input>
<br><br>
<label>Date of Birth:</label>
<input type="date" id="DOB" onchange="calculateAge()" name = "dob"></input>
<br><br>
<label>Blood Group:</label>
<select name="blood_group" name = "bloodGroup">
<option value="A+">A+</option>
<option value="A-">A-</option>
<option value="B+">B+</option>
<option value="B-">B-</option>
<option value="AB+">AB+</option>
<option value="AB-">AB-</option>
<option value="O+">O+</option>
<option value="O-">O-</option>
</select>
<br><br>
<label>Address: </label>
<textarea rows="1" cols="30" name = "address"></textarea>
<br><br>
<label>State: </label>
<select onchange="print_city('state', this.selectedIndex);" id="sts" name ="state" class="form-control" required></select>
<br><br>
<label for="">City: </label>
<select id ="state" class="form-control" name = "city" required></select>
<script language="javascript">print_state("sts");</script>
<br><br>
<label >Contact Number: </label>
<input id="phonenumber" type="tel" name = "phone"></input>
<br><br>
<label>Email ID: </label>
<input type="email" id="email" name="email"></input>
<br><br>
<label>Password: </label>
<input type="password" id="pass" placeholder="*" name = "pass">
<br><br>
<label>Confirm password: </label>
<input type="password" id="conf_pass" placeholder="*" name = "cpass"><br><br>
<button type="submit" id="sub" value="submit" onclick="phonevalidator();passvalidator();emailvalidator();validatingAge()">Submit</button>
</form>
</body>
</html>