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patient_patientreg.php
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<!DOCTYPE html>
<html lang="en" dir="ltr">
<head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<title>Register - Rx Clinic</title><!-- Prevent the demo from appearing in search engines -->
<meta name="robots" content="noindex"><!-- Simplebar -->
<link type="text/css" href="assets/vendor/simplebar.min.css" rel="stylesheet"><!-- App CSS -->
<link type="text/css" href="assets/css/app.css" rel="stylesheet">
<link type="text/css" href="assets/css/app.rtl.css" rel="stylesheet"><!-- Material Design Icons -->
<link type="text/css" href="assets/css/vendor-material-icons.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-material-icons.rtl.css" rel="stylesheet">
<!-- Font Awesome FREE Icons -->
<link type="text/css" href="assets/css/vendor-fontawesome-free.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-fontawesome-free.rtl.css" rel="stylesheet"><!-- ion Range Slider -->
<link type="text/css" href="assets/css/vendor-ion-rangeslider.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-ion-rangeslider.rtl.css" rel="stylesheet"><!-- Flatpickr -->
<link type="text/css" href="assets/css/vendor-flatpickr.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr.rtl.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr-airbnb.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr-airbnb.rtl.css" rel="stylesheet"><!-- Vector Maps -->
<link type="text/css" href="assets/vendor/jqvmap/jqvmap.min.css" rel="stylesheet">
</head>
<body class="layout-default">
<div class="preloader"></div>
<div class="mdk-drawer-layout js-mdk-drawer-layout" data-push data-responsive-width="992px" data-fullbleed>
<div class="mdk-drawer-layout__content">
<!-- Header Layout -->
<div class="mdk-header-layout js-mdk-header-layout" data-has-scrolling-region>
<!-- Header -->
<div id="header" class="mdk-header js-mdk-header m-0" data-fixed data-effects="waterfall" data-retarget-mouse-scroll="false">
<div class="mdk-header__content">
<div class="navbar navbar-expand-sm navbar-main navbar-light bg-white pr-0" id="navbar" data-primary>
<div class="container-fluid p-0">
<!-- Navbar toggler --><button class="navbar-toggler navbar-toggler-custom d-lg-none d-flex mr-navbar" type="button" data-toggle="sidebar"><span class="material-icons">short_text</span></button><!-- Navbar Brand --><a href="#" class="navbar-brand flex "><span>Register</a>
<div>
<a href="patient_request.php"><button type="button" class="btn btn-primary-dark" data-toggle="modal" data-target="#modal-login">BOOK NEW CONSULTATION</button></a>
</div>
<ul class="nav navbar-nav d-none d-md-flex">
<li class="nav-item dropdown"><a href="#notifications_menu" class="nav-link dropdown-toggle" data-toggle="dropdown" data-caret="false"><i class="material-icons nav-icon navbar-notifications-indicator">notifications</i></a>
<div id="notifications_menu" class="dropdown-menu dropdown-menu-right navbar-notifications-menu">
<div class="dropdown-item d-flex align-items-center py-2"><span class="flex navbar-notifications-menu__title m-0">Notifications</span><a href="javascript:void(0)" class="text-muted"><small>Clear
all</small></a></div>
<div class="navbar-notifications-menu__content" data-simplebar>
<div class="py-2">
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm" style="width: 32px; height: 32px;"><img src="assets/images/profilew.png" alt="Avatar" class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> approved your <a href="">consultation appointment.</a><br><small class="text-muted">1
hr
ago</small></div>
</div>
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm" style="width: 32px; height: 32px;"><img src="assets/images/profilew.png" alt="Avatar" class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> requested to reschedule your <a href="">consultation appointment.</a><br><small class="text-muted">1
hr
ago</small></div>
</div>
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm" style="width: 32px; height: 32px;"><img src="assets/images/profilew.png" alt="Avatar" class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> cancelled your <a href="">consultation appointment.</a><br><small class="text-muted">1
day
ago</small></div>
</div>
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm" style="width: 32px; height: 32px;"><img src="assets/images/profilew.png" alt="Avatar" class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> declined your <a href="">consultation appointment.</a><br><small class="text-muted">3
days
ago</small></div>
</div>
</div>
</div><a href="javascript:void(0);" class="dropdown-item text-center navbar-notifications-menu__footer">View
All</a>
</div>
</li>
<li class="nav-item"><a href="#events-drawer" data-toggle="sidebar" class="nav-link d-flex align-items-center"><i class="material-icons nav-icon">event_note</i><span class="badge badge-warning text-primary-dark rounded-circle badge-notifications">1</span></a>
</li>
</ul>
<div class="dropdown"><a href="#" data-toggle="dropdown" data-caret="false" class="dropdown-toggle navbar-toggler navbar-toggler-company border-left d-flex align-items-center ml-navbar"><span class="mr-3"><img src="assets/images/profilew.png" width="43" height="43" alt="avatar"></span></span></a>
<div id="company_menu" class="dropdown-menu dropdown-menu-right navbar-company-menu">
<div class="dropdown-item d-flex align-items-center py-2 navbar-company-info py-3">
<span class="mr-3"><img src="assets/images/profilew.png" width="43" height="43" alt="avatar"></span><span class="flex d-flex flex-column"><strong style="font-size: 1.125rem;">Ms. User Wan</strong><small class="text-muted">@msuserwan</small></span>
</div>
<div class="dropdown-divider"></div>
<a class="dropdown-item d-flex align-items-center py-2" href="patient_myprofile.php"><span class="material-icons mr-2">person</span>My
Profile</a>
<a class="dropdown-item d-flex align-items-center py-2" href="patient_changepassword.php"><span class="material-icons mr-2">lock</span>Change Password</a>
<!-- <a class="dropdown-item d-flex align-items-center py-2"
href="changepasswordadmin.php"><span
class="material-icons mr-2">lock</span>Change Password</a> -->
</div>
</div>
</div>
</div>
</div>
</div><!-- // END Header -->
<!-- Header Layout Content -->
<div class="mdk-header-layout__content mdk-header-layout__content--fullbleed mdk-header-layout__content--scrollable page">
<div class="container-fluid page__container">
<div class="card card-form">
<div class="row no-gutters">
<div class="col-lg-4 card-body">
<div class="d-flex flex-column justify-content-center align-items-center mt-0 mb-2 navbar-light">
<a href="#" class="navbar-brand text-center mb-2 mr-0" style="min-width: 0"><img class="navbar-brand-icon" src="assets/images/profilew.png" width="320" alt="Flat"><span></span></a>
</div>
</div>
<div class="col-lg-8 card-form__body card-body bg-white">
<div class="modal-body">
<div class="row">
<div class="col">
<div class="form-group"><label class="text-label" for="fname">Email
Address:</label><input id="fname" type="text" required="" class="form-control" placeholder="Patient ID" value="[email protected]" disabled></div>
</div>
</div>
<div class="row">
<div class="col">
<div class="form-group"><label class="text-label" for="fname">First
Name:</label><input id="fname" type="text" required="" class="form-control" placeholder="First name" value=""></div>
</div>
<div class="col">
<div class="form-group"><label class="text-label" for="lname">Middle
Name:</label><input id="lname" type="text" class="form-control" placeholder="Middle name" value=""></div>
</div>
<div class="col">
<div class="form-group"><label class="text-label" for="lname">Last
Name:</label><input id="lname" type="text" required="" class="form-control" placeholder="Last name" value=""></div>
</div>
</div>
<div class="row">
<div class="col">
<div class="form-group"><label class="text-label" for="flatpickrSample01">Date:</label><input id="flatpickrSample01" type="text" class="form-control" placeholder="Flatpickr example" data-toggle="flatpickr" value="today"></div>
</div>
<div class="col">
<div class="form-group"><label class="text-label" for="fname">Cell
No:</label><input id="fname" type="text" required="" class="form-control" placeholder="Contact No." value="09987654321">
</div>
</div>
</div>
<div class="row">
<div class="col">
<div class="form-group"><label class="text-label" for="lname">Address:</label><input id="lname" type="text" class="form-control" placeholder="@username" value="">
</div>
</div>
</div>
<div class="row">
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="select01">Sex:</label>
<select id="select01" data-toggle="select" class="form-control">
<option selected="">M</option>
<option>F</option>
</select>
</div>
</div>
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="select01">Civil Status:</label>
<select id="select01" data-toggle="select" class="form-control">
<option selected="">Single</option>
<option>Single Parent</option>
<option>Married</option>
<option>Divorced</option>
<option>Widowed</option>
</select>
</div>
</div>
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="lname">Religion:</label><input id="lname" type="text" class="form-control" placeholder="Religion" value="">
</div>
</div>
</div>
<div class="row">
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="select01">Condition Status:</label>
<select id="select01" data-toggle="select" class="form-control">
<option selected="">None</option>
<option>PWD</option>
<option>Seniorn Citizen</option>
</select>
</div>
</div>
<div class="col-lg-2">
<div class="form-group"><label class="text-label" for="lname">Weight:</label><input id="lname" type="number" class="form-control" placeholder="Weight" value="">
</div>
</div>
<div class="col-lg-3">
<div class="form-group"><label class="text-label" for="lname">Height (ft):</label><input id="lname" type="number" class="form-control" placeholder="Heigh (ft)" value="">
</div>
</div>
<div class="col-lg-3">
<div class="form-group"><label class="text-label" for="lname">Height (in):</label><input id="lname" type="number" class="form-control" placeholder="Height (in)" value="">
</div>
</div>
</div>
<div class="row">
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="lname">BMI:</label><input id="lname" type="number" class="form-control" placeholder="BMI" value="" disabled>
</div>
</div>
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="select01">BMI Status:</label>
<select id="select01" data-toggle="select" class="form-control" disabled>
<option selected="">None</option>
<option>PWD</option>
<option>Seniorn Citizen</option>
</select>
</div>
</div>
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="lname">Temperature (Celcius):</label><input id="lname" type="number" class="form-control" placeholder="Temperature" value="" disabled>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="lname">BP Systolic:</label><input id="lname" type="number" class="form-control" placeholder="BP Systolic" value="" disabled>
</div>
</div>
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="lname">BP Diastolic:</label><input id="lname" type="number" class="form-control" placeholder="BP Diastolic" value="" disabled>
</div>
</div>
<div class="col-lg-4">
<div class="form-group"><label class="text-label" for="select01">Blood Type:</label>
<select id="select01" data-toggle="select" class="form-control" disabled>
<option selected="">O+</option>
<option>O-</option>
<option>AB+</option>
<option>AB-</option>
<option>A+</option>
<option>A-</option>
<option>B+</option>
<option>B-</option>
</select>
</div>
</div>
</div>
<div class="modal-footer">
<!-- <button type="button" class="btn btn-light" data-dismiss="modal">Close</button> -->
<a href="patient_index.php"><button type="button" class="btn btn-dark">Register
</button></a>
</div>
</div>
</div>
</div>
</div>
</div>
</div><!-- // END header-layout__content -->
</div><!-- // END header-layout -->
</div><!-- // END drawer-layout__content -->
<!--MODALS-->
<!-- Info Modal -->
<div id="modal-info" class="modal fade" tabindex="-1" role="dialog" aria-hidden="true">
<div class="modal-dialog modal-dialog-centered">
<div class="modal-content">
<div class="modal-body">
<div class="px-3">
<div class="d-flex justify-content-center mt-0 mb-0 navbar-light"><a href="#" class="navbar-brand" style="min-width: 0"><img class="navbar-brand-icon" src="assets/img/rxlogowithname.png" width="250" alt="Stack"></a></div><br><br>
<div><span><strong>PRESCRIPTION DETAILS</strong></span></div>
<div class="page-separator"></div>
<div class="modal-body">
<p><strong>Prescription Code: </strong>2022-0001</p>
<p><strong>Personnel: </strong>Dr. Number Wan</p>
<p><strong>Date: </strong>Aug 08, 2022</p>
<p><strong>Medicine: </strong>ibuprofen (Motrin® or Advil®)</p>
<p><strong>Remarks: </strong>Take 400–600 mg every 6–8 hours. Ibuprofen will help with
pain relief and as an anti-inflammatory.</p>
<!-- <br>
<div class="alert alert-soft-success d-flex" role="alert"><i class="material-icons mr-3">check_circle</i>
<div class="text-body">Your appointment is now <strong>APPROVED</strong>. Please proceed to the clinic according to the schedule.</div>
</div> -->
</div><!-- // END .modal-body -->
</div>
</div><!-- // END .modal-body -->
<div class="modal-footer"><a href="index_patient.php"><button type="button" class="btn btn-light" data-dismiss="modal">Close</button></a><a href="#"><button type="button" class="btn btn-dark" data-dismiss="modal">Print</button></a></div>
<!-- // END .modal-footer -->
</div><!-- // END .modal-content -->
</div><!-- // END .modal-dialog -->
</div><!-- // END .modal -->
<!-- Cancel Alert Modal -->
<div id="modal-cancel" class="modal fade" tabindex="-1" role="dialog" aria-hidden="true">
<div class="modal-dialog modal-dialog-centered modal-sm">
<div class="modal-content bg-danger">
<div class="modal-body text-center p-4"><i class="material-icons icon-40pt text-white mb-2">clear</i>
<h4 class="text-white">Cancelled!</h4>
<p class="text-white mt-3">You cancelled an appointment.</p><button type="button" class="btn btn-light my-2" data-dismiss="modal">Continue</button>
</div><!-- // END .modal-body -->
</div><!-- // END .modal-content -->
</div><!-- // END .modal-dialog -->
</div><!-- // END .modal -->
<div class="mdk-drawer js-mdk-drawer" id="default-drawer" data-align="start">
<div class="mdk-drawer__content">
<div class="sidebar sidebar-dark sidebar-left simplebar" data-simplebar>
<div class="d-flex align-items-center sidebar-p-a border-bottom sidebar-account flex-shrink-0"><a href="#" class="flex d-flex align-items-center text-underline-0 text-body"><span class="mr-3"><img src="assets/img/rxcliniclogowithoutline.png" width="43" height="43" alt="avatar"></span><span class="flex d-flex flex-column"><strong style="font-size: 25px;">Rx Clinic</strong><small class="text-muted text-uppercase" style="color: rgba(255,255,255,.54)"></small></span></a>
</div>
<!-- <div
class="sidebar-stats row no-gutters align-items-center text-center border-bottom flex-shrink-0">
<div class="sidebar-stats__col col">
<div class="sidebar-stats__title">Total Patients</div>
<div class="sidebar-stats__value">542</div>
</div>
<div class="sidebar-stats__col col border-left">
<div class="sidebar-stats__title">Total Appointments</div>
<div class="sidebar-stats__value">719</div>
</div>
</div> -->
<!-- <div class="py-4 text-center flex-shrink-0"><a style="min-width: 157px;" href="/signup.php"
class="btn btn-primary">Create <i class="material-icons ml-1">add</i></a></div> -->
<ul class="nav nav-tabs sidebar-tabs flex-shrink-0" role="tablist">
<li class="nav-item"><a class="nav-link active show" id="sm-menu-tab" href="#sm-menu" data-toggle="tab" role="tab" aria-controls="sm-menu" aria-selected="true">Menu</a></li>
<!-- <li class="nav-item"><a class="nav-link" href="#sm-account" data-toggle="tab">Manage</a></li> -->
<!-- <li class="nav-item"><a class="nav-link" href="#sm-settings" data-toggle="tab">Settings</a></li> -->
</ul>
<div class="tab-content">
<div id="sm-menu" class="tab-pane show active" role="tabpanel" aria-labelledby="sm-menu-tab">
<ul class="sidebar-menu flex">
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_index.php"><i class="sidebar-menu-icon sidebar-menu-icon--left material-icons">donut_small</i><span class="sidebar-menu-text">Dashboard</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_consultations.php"><i class="sidebar-menu-icon sidebar-menu-icon--left material-icons">date_range</i><span class="sidebar-menu-text">My Consultations</span><span class="badge badge-warning rounded-circle badge-notifications ml-auto" style="padding: .1875rem .375rem;">2</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_mydoctors.php"><i class="sidebar-menu-icon sidebar-menu-icon--left material-icons">person</i><span class="sidebar-menu-text">My Doctors</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_prescriptions.php"><i class="sidebar-menu-icon sidebar-menu-icon--left material-icons">description</i><span class="sidebar-menu-text">Reports</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_payments.php"><i class="sidebar-menu-icon sidebar-menu-icon--left material-icons">payment</i><span class="sidebar-menu-text">Payment</span></a></li>
</ul>
</div>
</div>
<div class="mt-auto sidebar-p-a sidebar-b-t d-flex flex-column flex-shrink-0">
<a class="sidebar-link mb-2" href="#">Register<i class="sidebar-menu-icon ml-2 material-icons icon-16pt">person</i></a>
<a class="sidebar-link" href="landingpagelogin.php"><strong>LOG OUT</strong><i class="sidebar-menu-icon ml-2 material-icons icon-16pt">exit_to_app</i></a>
</div>
</div>
</div>
</div>
</div><!-- // END drawer-layout -->
<div class="mdk-drawer js-mdk-drawer" id="events-drawer" data-align="end">
<div class="mdk-drawer__content">
<div class="sidebar sidebar-light sidebar-left simplebar" data-simplebar>
<small class="text-dark-gray px-3 py-1"><strong>Sunday, 07 Aug</strong></small>
<div class="list-group list-group-flush">
<div class="list-group-item bg-light">
<div class="row">
<div class="col-auto d-flex flex-column"><small>9:00 AM</small><small class="text-dark-gray">1 hr</small></div>
<div class="col">
<div class="d-flex flex-column flex"><a href="#" class="text-body"><strong class="text-15pt">Cardiology</strong></a><small class="text-muted d-flex align-items-center"><i class="material-icons icon-16pt mr-1">person</i>Dr. Number Wan</small>
</div>
<div class="avatar-group mt-2">
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