ikan Uploader :
Directory : /var/www/html/shardahospital.org/cowin/application/views/
Upload File : |
| Current File : /var/www/html/shardahospital.org/cowin/application/views/edit_cprofile.php |
<div class="container">
<div class="row">
<div class="col col-lg-12">
<div class="login-header">
<!-- <p>Already a Member?</p>
<button type="button" class="btn btn-primary header-btn" onclick="window.location.href = 'login.html';">Login </button>-->
</div>
</div>
</div>
</div>
<div class="container">
<div class="row">
<div class="col-lg-3"></div>
<div class="col-lg-6">
<div class="login-rectangle">
<a href="<?=base_url('companydashboard')?>" class="backtodash"><i class="fa fa-arrow-left" aria-hidden="true"></i> Back </a>
<div class="login-logo">
<img src="<?=base_url('assests/imgs')?>/logo_new.png">
</div>
<form action="" method="POST" enctype="multipart/form-data">
<?php if (validation_errors()) { ?>
<div class="alert alert-danger"><?= validation_errors() ?></div>
<?php } ?>
<div class="login-sec">
<h2>Your Details</h2>
<p>Your Photo ID will be verified at the time of your Covid-19 Test appointment. </p>
<select name="id_proof" id="id_proof" required>
<option value="" >Photo Id Proof</option>
<?php foreach($proofArray as $row) { ?>
<option value="<?=$row['title']?>" <?php if($row['title']==$recored['id_proof']) { echo 'selected'; }?>><?=$row['title']?></option>
<?php } ?>
<option value="<?php echo $recored['id_proof'] ?>" selected ><?php echo $recored['id_proof'] ?></option>
</select>
<input type="hidden" name="id" id="id" value="<?=$recored['id']?>" />
<input type="text" name="full_name" id="full_name" value="<?=$recored['full_name']?>" autocomplete=OFF maxlength=245 placeholder="Name (as in Adhaar No)" required>
<input type="text" name="aadhar_number" value="<?=$recored['aadhar_number']?>" id="aadhar_number" onkeyup="this.value=this.value.replace(/[^\d]/,'')" autocomplete=OFF maxlength=12 placeholder="Beneficiary ID Number" required>
<input type="email" name="email_id" id="email_id" value="<?=$recored['email_id']?>" autocomplete=OFF maxlength=120 placeholder="Beneficiary Email ID">
<input type="date" name="dob" id="dob" autocomplete=OFF value="<?=$recored['dob']?>" placeholder="Beneficiary DOB(as in ID Proof)" required>
<div class="radio-btn">
<span>Upload Photo id Proof(Aadhar Card)</span>
<a href="<?=base_url('attachments/documents/'.$recored['photo_proof'])?>" target="_blank"><?=$recored['photo_proof']?></a>
<input type="file" name="photo_proof" id="photo_proof" placeholder="Upload Photo id Proof">
<small>(Only jpg, jpeg, png and pdf allowed)</small>
<input type="hidden" name="old_document" id="old_document" value="<?=$recored['photo_proof']?>" />
</div>
<div class="radio-btn">
<span>Gender</span>
<label><input type="radio" name="gender" id="gender" value="Male" <?php if($recored['gender']=='Male'){ ?>checked <?php } ?>>Male </label>
<label><input type="radio" name="gender" id="gender" value="Female" <?php if($recored['gender']=='Female'){ ?>checked <?php } ?>>Female </label>
<label><input type="radio" name="gender" id="gender" value="Other" <?php if($recored['gender']=='Other'){ ?>checked <?php } ?>>Other </label>
</div>
<!--<div class="radio-btn">
<span>Do you want collection from home?</span>
<small></small>
<label><input type="radio" name="onsite_collection" value="Yes" <?php if($recored['onsite_collection']=='Yes'){ ?>checked <?php } ?> >Yes </label>
<label><input type="radio" name="onsite_collection" value="No" checked <?php if($recored['onsite_collection']=='No'){ ?>checked <?php } ?> >No </label>
</div>-->
<div class="radio-btn">
<span style="color:red;">*All Fileds are mandatory</span>
</div>
<button type="submit" class="btn btn-primary login-btn">Save </button>
</div>
</form>
<div class="login-pin"></div>
</div>
</div>
<div class="col col-lg-3"></div>
</div>
</div>
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