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staff_submit_sample_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>Submit Sample Information </h2>
</div>
</div>
<div class="col-md-6">
<div class="about-img">
<img src="assets/img/login.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="staff_submit_sample_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 Age:</label>
<input type="text" placeholder="Age" name="Age" required >
</div>
<div class="input-form">
<label for="">Patient Email:</label>
<input type="text" placeholder="Email" name="Email" required>
</div>
<div class="input-form">
<label for="">Gender:</label>
<select name="Sex">
<option value="Male" > Male</option>
<option value="Female"> Female</option>
<option value="Others"> Others</option>
</select>
</div>
<div class="input-form">
<label for=""> Sample type:</label>
<select name="Sample_type">
<option value="Blood" > Blood</option>
<option value="Urine"> Urine</option>
<option value="X-ray"> X-ray</option>
</select>
</div>
<div class="input-form">
<label for=""> Date of delivery:</label>
<input type="Date" placeholder="Date of delivery" name="Date_of_delivery" required>
</div>
<div class="input-form">
<label for=""> Date of payment: </label>
<input type="Date" placeholder="Date of payment" name="Date_of_payment" required>
</div>
<br>
<button class="btn btn_one"> <b> Submit </b></button>
</form>
</p>
</center>
</div>
</div>
</div>
</div>
</div>
</div>
</body>