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index_form.html
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index_form.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta http-equiv="X-UA-Compatible" content="ie=edge">
<title>Patient Details Entry form</title>
<link href="https://maxcdn.bootstrapcdn.com/font-awesome/4.7.0/css/font-awesome.min.css" rel="stylesheet" integrity="sha384-wvfXpqpZZVQGK6TAh5PVlGOfQNHSoD2xbE+QkPxCAFlNEevoEH3Sl0sibVcOQVnN" crossorigin="anonymous">
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/animate.css/3.5.2/animate.css" />
<link rel="stylesheet" href="style2.css">
</head>
<body>
<div class="container">
<h1 class="brand"><span>Patient's</span> History Records</h1>
<div class="wrapper">
<div class="company-info">
<h3>Patient Details Form</h3>
<ul>
<li><i class="fa fa-road"></i>NewLife Hospital</li>
<li><i class="fa fa-phone"></i> 021-34512777</li>
<li><i class="fa fa-envelope"></i> [email protected]</li>
</ul>
</div>
<div class="contact">
<h3>Enter Details</h3>
<div class="alert">Your message has been sent</div>
<form id="DetailsForm">
<p>
<label>Patient Name</label>
<input type="text" name="name" id="name" required>
</p>
<p>
<label>Date Of Birth</label>
<input type="text" name="dob" id="dob">
</p>
<p>
<label>Disease</label>
<input type="text" name="disease" id="disease" required>
</p>
<p>
<label>Cost</label>
<input type="text" name="cost" id="cost" required>
</p>
<p>
<label>Date Of Arrival</label>
<input type="date" name="doa" id="doa">
</p>
<p class="full">
<label>Medicaion Provided</label>
<textarea name="message" rows="5" id="message"></textarea>
</p>
<p class="full">
<button type="submit">Submit</button>
</p>
</form>
</div>
</div>
</div>
<script src="https://www.gstatic.com/firebasejs/5.7.2/firebase.js"></script>
<script>
// Initialize Firebase
var config = {
apiKey: "AIzaSyDwCMoU5WpLuvHXaZ5p6eebhKJFQZYzvzg",
authDomain: "signup-e052f.firebaseapp.com",
databaseURL: "https://signup-e052f.firebaseio.com",
projectId: "signup-e052f",
storageBucket: "signup-e052f.appspot.com",
messagingSenderId: "409757591025"
};
firebase.initializeApp(config);
</script>
<script src="main.js"></script>
</body>
</html>