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patient_registration_form.php
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<?php include 'header.php'; ?>
<body>
<div class="about-area section-padding" id="about">
<div class="container">
<div class="row">
<div class="col-md-12">
<div class="about-title">
<h2>Patient Registration</h2>
</div>
</div>
<div class="col-md-6">
<div class="about-img">
<img src="assets/img/sm-img.svg" alt="pathology-image">
</div>
</div>
<div class="col-md-4 offset-md-2">
<div class="about-content">
<div class="login-box">
<center>
<p>
<form action="patient_registration_link.php" method="post">
<div class="input-form">
<label for=""> Patient Name: </label>
<input type="text" placeholder="Patient name" name="Patient_name" required >
</div>
<div class="input-form">
<label for=""> Patient Number: </label>
<input type="text" placeholder="Phone number" name="Phone_number" required >
</div>
<div class="input-form">
<label for=""> Address: </label>
<input type="text" placeholder="Address" name="Address" required>
</div>
<div class="input-form">
<label for=""> Email: </label>
<input type="text" placeholder="Email" name="Email" required>
</div>
<div class="input-form">
<label for=""> Password: </label>
<input type="Password" placeholder="Password" name="Password" required>
</div>
<div class="input-form">
<label for=""> Date: </label>
<input type="Date" placeholder="Date of registration..." name="Date_of_register" required>
</div>
<br>
<p> Already have an account?* <a href="login_form.php"> Log-in </a> </p>
<button class="btn btn_one"><b>Submit</b></button>
</form>
</p>
</center>
</div>
</div>
</div>
</div>
</div>
</div>
</body>