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GamerBhai02

Program 2 Registration Form

GamerBhai02
Dec 19th, 2024
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  1. <!DOCTYPE html>
  2. <html>
  3. <head>
  4.   <title>Doctor Registration Form</title>
  5.   <style>
  6.     .container {
  7.       display: flex;
  8.     }
  9.   </style>
  10. </head>
  11. <body>
  12.   <div class="container">
  13.     <div>
  14.       <img src="C:\Users\Abu Talha\Desktop\doctor.png" alt="Doctor Image" width="700" height="600">
  15.     </div>
  16.     <div>
  17.       <h2>Doctor Registration Form</h2>
  18.       <form>
  19.         <label for="appointmentDate">Appointment Date:</label>
  20.         <input type="date" id="appointmentDate" name="appointmentDate"><br><br>
  21.         <label for="appointmentTime">Appointment Time:</label>
  22.         <input type="time" id="appointmentTime" name="appointmentTime"><br><br>
  23.         <label for="firstName">Name:</label>
  24.         <input type="text" id="firstName" name="firstName" placeholder="First">
  25.         <input type="text" id="lastName" name="lastName" placeholder="Last"><br><br>
  26.         <label>Gender:</label><br>
  27.         <input type="radio" id="male" name="gender" value="male">
  28.         <label for="male">Male</label><br>
  29.         <input type="radio" id="female" name="gender" value="female">
  30.         <label for="female">Female</label><br><br>
  31.         <label for="phone">Phone:</label>
  32.         <input type="tel" id="phone" name="phone"><br><br>
  33.         <label for="city">City:</label>
  34.         <input type="text" id="city" name="city"><br><br>
  35.         <label for="state">State:</label>
  36.         <input type="text" id="state" name="state"><br><br>
  37.         <label for="query">Your Query:</label>
  38.         <textarea id="query" name="query" rows="4"></textarea><br><br>
  39.         <label for="appointmentType">Appointment Type:</label><br>
  40.         <select id="appointmentType" name="appointmentType" required>
  41.           <option value="cervixCheckup">Cervix checkup</option>
  42.           <option value="heartCheckup">Heart checkup</option>
  43.           <option value="eyeCheckup">Eye check-up</option>
  44.           <option value="hearingTest">Hearing Test</option>
  45.         </select><br><br>
  46.         <input type="submit" value="Submit">
  47.         <input type="reset" value="Reset">
  48.       </form>
  49.     </div>
  50.   </div>
  51. </body>
  52. </html>
Tags: Appointment Form
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