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1.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8" content="width=device-width, initial-scale=1">
<title>WebWork</title>
<link rel="stylesheet" href="custom/customthree.css">
<link href="BP/bootstrap-4.3.1-dist/css/bootstrap.min.css" rel="stylesheet">
<script src="BP/js/jquery-3.4.1.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.14.7/umd/popper.min.js"></script>
<script src="BP/bootstrap-4.3.1-dist/js/bootstrap.min.js"></script>
</head>
<body>
<header class="header">
<nav class="navbar navbar-style" data-toggle="collapse">
<div class="container-fluid">
<a href="#" class="navbar-brand mr-3"> Aid Hospital</a>
<button type="button" class="navbar-toggler" data-toggle="collapse" data-target="#menu">
<span class="navbar-toggle-icon"></span>
<span class="navbar-toggle-icon"></span>
<span class="navbar-toggle-icon"></span>
<span class="navbar-toggle-icon"></span>
<span class="navbar-toggle-icon"></span>
</button>
<div class="navbar-header">
<img src="resawces/nk.jpg" class="logo" alt="logo">
</div>
<div class="collapse navbar-collapse" id="menu" >
</div>
<ul class="nav justify-content-end">
<li class="nav-item"><a class="nav-link" href="tut.html">Home</a></li>
<li class="nav-item" ><a class="nav-link active" href="1.html">Registration</a></li>
<li class="nav-item" ><a class="nav-link" href="2.html">Contact</a></li>
<li class="nav-item" ><a class="nav-link" href="4.html">Records</a></li>
<li class="nav-item" ><a class="nav-link" href="3.html">About</a></li>
</ul>
</div>
</nav>
<div class="jumbotron text-center">
<h1>Welcome to Aid Hospital</h1>
<p>Addressing all your needs.</p>
</div>
</header>
<div class="register">
<div class="container1 col-md-6" >
<h2>Patient Form:</h2>
<form action=" " method="post" class="needs-validation" novalidate>
<!-- /action_page.php -->
<div class="form-group">
<label for="pid">Patient id:</label>
<input type="text" class="form-control" id="pid" placeholder="Enter patient id" name="pid" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="fname">First Name:</label>
<input type="text" class="form-control" id="fname" placeholder="Enter first name" name="fname" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="sname">Surname:</label>
<input type="text" class="form-control" id="sname" placeholder="Enter surname" name="sname" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="mname">Middle name:</label>
<input type="text" class="form-control" id="mname" placeholder="Enter middle name" name="mname" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="dob">Date of birth:</label>
<input type="date" class="form-control" id="dob" placeholder="Enter date of birth" name="dob" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="gnd">Gender:</label>
<!-- <input type="" class="form-control" id="gnd" placeholder="Choose gender" name="gnd" required>-->
<select name="gnd" id="gnd" class="custom-select">
<option value="female">Female</option>
<option value="male">Male</option>
<option value="box">Box Sexes</option>
</select>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="county">County:</label> <br>
<!-- <input type="" class="form-control" id="county" placeholder="Choose County" name="county" required>-->
<select name="county" id="county" class="custom-select">
<option value="1">Mombasa</option>
<option value="2">Kwale</option>
<option value="3">Kilifi</option>
<option value="4">Tana River</option>
<option value="5">Lamu</option>
<option value="6">Taita–Taveta</option>
<option value="7">Garissa</option>
<option value="8">Wajir</option>
<option value="9">Mandera</option>
<option value="10">Marsabit</option>
<option value="11">Isiolo</option>
<option value="12">Meru</option>
<option value="13">Tharaka-Nithi</option>
<option value="14">Embu</option>
<option value="15">Kitui</option>
<option value="16">Machakos</option>
<option value="17">Makueni</option>
<option value="18">Nyandarua</option>
<option value="19">Nyeri</option>
<option value="20">Kirinyaga</option>
<option value="21">Murang'a</option>
<option value="22">Kiambu</option>
<option value="23">Turkana</option>
<option value="24">West Pokot</option>
<option value="25">Samburu</option>
<option value="26">Trans-Nzoia</option>
<option value="27">Uasin Gishu</option>
<option value="28">Elgeyo-Marakwet</option>
<option value="29">Nandi</option>
<option value="30">Baringo</option>
<option value="31">Laikipia</option>
<option value="32">Nakuru</option>
<option value="33">Narok</option>
<option value="34">Kajiado</option>
<option value="35">Kericho</option>
<option value="36">Bomet</option>
<option value="37">Kakamega</option>
<option value="38">Vihiga</option>
<option value="39">Bungoma</option>
<option value="40">Busia</option>
<option value="41">Siaya</option>
<option value="42">Kisumu</option>
<option value="43">Homa Bay</option>
<option value="44">Migori</option>
<option value="45">Kisii</option>
<option value="46">Nyamira</option>
<option value="47">Nairobi</option>
</select>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group form-check">
<label class="form-check-label">
<input class="form-check-input" type="checkbox" name="remember" required> I agree to the terms and conditions.
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Check this checkbox to continue.</div>
</div>
<button type="submit" class="btn btn-light">Clear</button>
<button type="submit" class="btn btn-primary">Send</button>
</form>
</div>
<div class="container2 col-md-6">
<h2> Next of Kin Form:</h2>
<form action=" " method="post" class="needs-validation" novalidate>
<!-- /action_page.php -->
<div class="form-group">
<label for="pid">Patient id:</label>
<input type="text" class="form-control" id="pid" placeholder="Enter patient id" name="pid" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="fname">First Name:</label>
<input type="text" class="form-control" id="fname" placeholder="Enter first name" name="fname" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="sname">Surname:</label>
<input type="text" class="form-control" id="sname" placeholder="Enter surname" name="sname" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<div class="form-group">
<label for="rship">Relationship:</label>
<input type="text" class="form-control" id="rship" placeholder="What is your relationship" name="rship" required>
<div class="valid-feedback">Valid.</div>
<div class="invalid-feedback">Please fill out this field.</div>
</div>
<button type="submit" class="btn btn-primary">Send</button>
</form>
</div>
</div>
<script>
// Disable form submissions if there are invalid fields
(function() {
'use strict';
window.addEventListener('load', function() {
// Get the forms we want to add validation styles to
var forms = document.getElementsByClassName('needs-validation');
// Loop over them and prevent submission
var validation = Array.prototype.filter.call(forms, function(form) {
form.addEventListener('submit', function(event) {
if (form.checkValidity() === false) {
event.preventDefault();
event.stopPropagation();
}
form.classList.add('was-validated');
}, false);
});
}, false);
})();
</script>
<footer>
<div class="footer">
<p> ©2019.Copyright:AH.</p>
<p> Find us at: 75019 Wilma Drive Nakuru.</p>
<p>Contact information: [email protected].</p>
</div>
</footer>
</body>
</html>