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formulir-umum.php
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<!-- ======= Breadcrumbs ======= -->
<section class="breadcrumbs">
<div class="container">
<div class="d-flex justify-content-between align-items-center">
<h2>Form Pendaftaran ke Dokter Umum</h2>
<ol>
<li><a href="index.php">Home</a></li>
<li>Daftar Pelayanan</li>
<li>Form Pendaftaran ke Dokter Umum</li>
</ol>
</div>
</div>
</section>
<!-- End Breadcrumbs -->
<div class="container mb-5">
<div class="page-heading">
<div class="page-title text-center">
<br>
<h3>Formulir Pendaftaran Dokter Umum</h3>
<p class="text-subtitle text-muted">Anda dapat mengisi formulir pendaftaran Dokter Umum disini</p>
</div>
<br>
<div class="card w-75 mx-auto">
<div class="card-content">
<div class="card-body">
<div class="container text-start">
<form class="form form-horizontal" action="controller/aksi.php?aksi=umum" method="post">
<div class="form-body">
<div class="row">
<div class="col-md-4">
<label>Layanan</label>
</div>
<div class="col-md-8 form-group mb-2">
<input value="Dokter Umum" name="layanan" type="text" class="form-control" id="disabledInput" placeholder="Dokter Umum"
disabled>
</div>
<div class="col-md-4">
<label>Nama Lengkap</label>
</div>
<div class="col-md-8 form-group mb-2">
<input type="text" id="namalengkap" class="form-control" name="nama"
placeholder="Nama Lengkap Anda" required>
</div>
<div class="col-md-4">
<label>Kota</label>
</div>
<div class="col-md-8 form-group mb-2">
<input type="text" id="kota" class="form-control" name="kota"
placeholder="Kota Anda" required>
</div>
<div class="col-md-4">
<label>Tanggal Lahir</label>
</div>
<div class="col-md-8 form-group mb-2">
<input type="date" id="tanggallahir" class="form-control" name="tanggallahir"
placeholder="Tanggal Lahir Anda" required>
</div>
<div class="col-md-4">
<label>Email</label>
</div>
<div class="col-md-8 form-group mb-2">
<input type="email" id="email" class="form-control" name="email"
placeholder="Email" required>
</div>
<div class="col-md-4">
<label>No. HP</label>
</div>
<div class="col-md-8 form-group mb-2">
<input type="number" id="hp" class="form-control" name="notelp"
placeholder="No. HP Anda" required>
</div>
<div class="col-md-4">
<label>Keluhan</label>
</div>
<div class="col-md-8 form-group mb-2">
<textarea class="form-control" id="exampleFormControlTextarea1" rows="3" name="keluhan" placeholder="Masukkan Keluhan Yang Anda Rasakan" required></textarea>
</div>
<div class="col-sm-12 d-flex justify-content-end">
<button type="submit" class="btn btn-primary me-1 mb-1">Submit</button>
<button type="reset"
class="btn btn-light-secondary btn-outline-danger me-1 mb-1">Reset</button>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</div>