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Directory : /var/www/html/shardahospital.org/cowin/application/views/
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| Current File : /var/www/html/shardahospital.org/cowin/application/views/my_profile_old.php |
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<title>Covid-19 Test | My Profile Page</title>
<link href="css/bootstrap-grid.css" rel="stylesheet" type="text/css">
<link href="css/bootstrap-reboot.css" rel="stylesheet" type="text/css">
<link href="css/bootstrap.css" rel="stylesheet" type="text/css">
<link href="css/font-awesome.min.css" rel="stylesheet">
<link href="css/style.css" rel="stylesheet" type="text/css">
</head>
<body>
<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 col-lg-3"></div>
<div class="col col-lg-6">
<div class="login-rectangle">
<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>Provide Your Details</h2>
<p>Your Photo ID will be verified at the time of your covid 19 vaccination, please provide the detail of the photo ID you will carry for Covid-19 vaccination. </p>
<select name="id_proof" id="id_proof">
<option value="" >Photo Id Proof</option>
<?php foreach($proofArray as $row) { ?>
<option value="<?=$row['title']?>"><?=$row['title']?></option>
<?php } ?>
</select>
<input type="text" name="full_name" id="full_name" autocomplete=OFF maxlength=245 placeholder="Beneficiary Name (as in ID Proof)" required>
<input type="text" name="aadhar_number" id="aadhar_number" autocomplete=OFF maxlength=12 placeholder="Beneficiary ID numbe" required>
<input type="email" name="email_id" id="email_id" autocomplete=OFF maxlength=12 placeholder="Beneficiary Email ID">
<input type="date" name="dob" id="dob" autocomplete=OFF maxlength=12 placeholder=" Beneficiary DOB(as in ID Proof)" required>
<div class="radio-btn">
<span>Upload Photo id Proof(Aadhar Card)</span>
<input type="file" name="photo_proof" id="photo_proof" placeholder="Upload Photo id Proof" required>
<small>(Only jpg, jpeg, png and pdf allowed)</small>
</div>
<div class="radio-btn">
<span>Gender</span>
<label><input type="radio" name="gender" id="gender" value="Male" checked>Male </label>
<label><input type="radio" name="gender" id="gender" value="Female">Female </label>
<label><input type="radio" name="gender" id="gender" value="Other">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" >Yes </label>
<label><input type="radio" name="onsite_collection" value="No" checked >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">Register </button>
</div>
</form>
<div class="login-pin"></div>
</div>
</div>
<div class="col col-lg-3"></div>
</div>
</div>
</body>
</html>
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