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<!DOCTYPE html>
<html lang="en">
<!-- add-patient24:06-->
<head>
{% load static
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0, user-scalable=0">
<link rel="shortcut icon" type="image/x-icon" href="assets/img/favicon.ico">
<title>Preclinic - Medical & Hospital - Bootstrap 4 Admin Template</title>
<link rel="stylesheet" type="text/css" href="assets/css/bootstrap.min.css">
<link rel="stylesheet" type="text/css" href="assets/css/font-awesome.min.css">
<link rel="stylesheet" type="text/css" href="assets/css/select2.min.css">
<link rel="stylesheet" type="text/css" href="assets/css/dataTables.bootstrap4.min.css">
<link rel="stylesheet" type="text/css" href="assets/css/bootstrap-datetimepicker.min.css">
<link rel="stylesheet" type="text/css" href="assets/css/style.css">
<!--[if lt IE 9]>
<script src="assets/js/html5shiv.min.js"></script>
<script src="assets/js/respond.min.js"></script>
<![endif]-->
</head>
<body>
<div class="main-wrapper">
<div class="header">
<div class="header-left">
<a href="dashboard.php" class="logo">
<img src="assets/img/logo.png" width="35" height="35" alt=""> <span>Preclinic</span>
</a>
</div>
<a id="toggle_btn" href="javascript:void(0);"><i class="fa fa-bars"></i></a>
<a id="mobile_btn" class="mobile_btn float-left" href="#sidebar"><i class="fa fa-bars"></i></a>
<ul class="nav user-menu float-right">
<li class="nav-item dropdown has-arrow">
<a href="#" class="dropdown-toggle nav-link user-link" data-toggle="dropdown">
<span class="user-img"><img class="rounded-circle" src="assets/img/user.jpg" width="40" alt="Admin">
<span class="status online"></span></span>
<span>Admin</span>
</a>
<div class="dropdown-menu">
<a class="dropdown-item" href="profile.php">My Profile</a>
<a class="dropdown-item" href="edit-profile.php">Edit Profile</a>
<a class="dropdown-item" href="settings.php">Settings</a>
<a class="dropdown-item" href="login.php">Logout</a>
</div>
</li>
</ul>
<div class="dropdown mobile-user-menu float-right">
<a href="#" class="nav-link dropdown-toggle" data-toggle="dropdown" aria-expanded="false"><i class="fa fa-ellipsis-v"></i></a>
<div class="dropdown-menu dropdown-menu-right">
<a class="dropdown-item" href="profile.php">My Profile</a>
<a class="dropdown-item" href="edit-profile.php">Edit Profile</a>
<a class="dropdown-item" href="settings.php">Settings</a>
<a class="dropdown-item" href="login.php">Logout</a>
</div>
</div>
</div>
<div class="sidebar" id="sidebar">
<div class="sidebar-inner slimscroll">
<div id="sidebar-menu" class="sidebar-menu">
<ul>
<li class="menu-title">Main</li>
<li>
<a href="dashboard.php"><i class="fa fa-dashboard"></i> <span>Dashboard</span></a>
</li>
<li>
<a href="doctors.php"><i class="fa fa-user-md"></i> <span>Doctors</span></a>
</li>
<li class="active">
<a href="patients.php"><i class="fa fa-wheelchair"></i> <span>Patients</span></a>
</li>
<li>
<a href="appointments.php"><i class="fa fa-calendar"></i> <span>Appointments</span></a>
</li>
<li>
<a href="schedule.php"><i class="fa fa-calendar-check-o"></i> <span>Doctor Schedule</span></a>
</li>
</ul>
</div>
</div>
</div>
<div class="page-wrapper">
<div class="content">
<div class="row">
<div class="col-lg-8 offset-lg-2">
<h4 class="page-title">Add Patient</h4>
</div>
</div>
<div class="row">
<div class="col-lg-8 offset-lg-2">
<form method="POST" action="assets/backend/controller.php?act=addPatient">
<div class="row">
<div class="col-sm-6">
<div class="form-group">
<label>First Name <span class="text-danger">*</span></label>
<input class="form-control" name="firstname" type="text" required>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<label>Last Name</label>
<input class="form-control" name="surname" type="text" required>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<label>Email <span class="text-danger">*</span></label>
<input class="form-control" name="email" type="email" required>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<label>Date of Birth</label>
<div class="cal-icon">
<input type="text" name="dob" class="form-control datetimepicker" required>
</div>
</div>
</div>
<div class="col-sm-6">
<div class="form-group">
<label>Phone </label>
<input class="form-control" name="phonenumber" type="text" required>
</div>
</div>
<div class="col-sm-6">
<div class="form-group gender-select">
<label class="gen-label">Gender:</label>
<div class="form-check-inline">
<label class="form-check-label">
<input type="radio" name="gender" class="form-check-input" value="Male" checked>Male
</label>
</div>
<div class="form-check-inline">
<label class="form-check-label">
<input type="radio" name="gender" class="form-check-input" value="Female">Female
</label>
</div>
</div>
</div>
<div class="col-sm-12">
<div class="row">
<div class="col-sm-12">
<div class="form-group">
<label>Address</label>
<input type="text" name="address" class="form-control" required>
</div>
</div>
<div class="col-sm-6 col-md-6 col-lg-3">
<div class="form-group">
<label>City</label>
<input type="text" name="city" class="form-control" required>
</div>
</div>
<div class="col-sm-6 col-md-6 col-lg-3">
<div class="form-group">
<label>State/Province</label>
<input type="text" name="province" class="form-control" required>
</div>
</div>
</div>
</div>
<div class="col-sm-6">
<label class="display-block">Status</label>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="status" id="patient_active" value="Active" checked>
<label class="form-check-label" for="patient_active">
Active
</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="radio" name="status" id="patient_inactive" value="Inactive">
<label class="form-check-label" for="patient_inactive">
Inactive
</label>
</div>
</div>
<!-- <div class="col-sm-6">
<div class="form-group">
<label>Avatar</label>
<div class="profile-upload">
<div class="upload-img">
<img alt="" src="assets/img/user.jpg">
</div>
<div class="upload-input">
<input type="file" class="form-control">
</div>
</div>
</div>
</div> -->
</div>
<div class="m-t-20 text-center">
<button class="btn btn-primary submit-btn">Create Patient</button>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
<div class="sidebar-overlay" data-reff=""></div>
<script src="assets/js/jquery-3.2.1.min.js"></script>
<script src="assets/js/popper.min.js"></script>
<script src="assets/js/bootstrap.min.js"></script>
<script src="assets/js/jquery.slimscroll.js"></script>
<script src="assets/js/select2.min.js"></script>
<script src="assets/js/moment.min.js"></script>
<script src="assets/js/bootstrap-datetimepicker.min.js"></script>
<script src="assets/js/app.js"></script>
</body>
<!-- add-patient24:07-->
</html>