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signup.php
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<!DOCTYPE html>
<html>
<head>
<meta charset="UTF-8">
<meta content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no" name="viewport">
<title>Daftar Terlebih Dahulu</title>
<!-- Favicon-->
<link rel="icon" href="favicon.ico" type="image/x-icon">
<!-- Google Fonts -->
<link href="assets/css/roboto.css" rel="stylesheet">
<!-- Material Icon Css -->
<link href="assets/css/material-icon.css" rel="stylesheet">
<!-- Bootstrap Core Css -->
<link href="plugins/bootstrap/css/bootstrap.css" rel="stylesheet">
<!-- Waves Effect Css -->
<link href="plugins/node-waves/waves.css" rel="stylesheet" />
<!-- Animation Css -->
<link href="plugins/animate-css/animate.css" rel="stylesheet" />
<!-- Custom Css -->
<link href="assets/css/style.css" rel="stylesheet">
<link href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-1BmE4kWBq78iYhFldvKuhfTAU6auU8tT94WrHftjDbrCEXSU1oBoqyl2QvZ6jIW3" crossorigin="anonymous">
<!-- AdminBSB Themes. You can choose a theme from css/themes instead of get all themes -->
<link href="assets/css/theme-green.css" rel="stylesheet" />
<link rel="icon" href="assets/img/logs1.png">
</head>
<body class="login-page">
<!-- Page Loader -->
<div class="page-loader-wrapper">
<div class="loader">
<div class="preloader">
<div class="spinner-layer pl-red">
<div class="circle-clipper left">
<div class="circle"></div>
</div>
<div class="circle-clipper right">
<div class="circle"></div>
</div>
</div>
</div>
<p>Memproses data ke server.....</p>
</div>
</div>
<!-- #END# Page Loader -->
<div class="login-box" style="margin: 20px;">
<div class="logo">
<p class="align-center"><img src="assets/img/logs1.png" width="150px"></p>
</div>
<div class="card rounded">
<div class="body">
<form action="./inc/daftarpasien.php" method="POST">
<!-- Name input -->
<div class="form-outline mb-4">
<label class="form-label" for="form5Example1">Nama Pasien</label>
<input type="text" id="form5Example1" class="form-control" name="nama" required/>
</div>
<label class="form-label" for="form5Example1">Jenis Kelamin</label>
<select class="form-select" aria-label="Default select example" name="jk" required>
<option selected required>-</option>
<option value="Laki-Laki">Laki-Laki</option>
<option value="Perempuan">Perempuan</option>
</select>
<div class="form-outline mb-4">
<label class="form-label" for="form5Example1">Alamat</label>
<input type="text" id="form5Example1" class="form-control" name="alamat" required/>
</div>
<div class="form-outline mb-4">
<label class="form-label" for="form5Example1">Tanggal Lahir</label>
<input type="date" id="form5Example1" class="form-control" name="tgl_lahir" required/>
</div>
<div class="form-outline mb-4">
<label class="form-label" for="form5Example1">Penanggung Jawab</label>
<input type="text" id="form5Example1" class="form-control" name="penjab" required/>
</div>
<div class="form-outline mb-4">
<label class="form-label" for="form5Example1">NO KTP</label>
<input type="text" id="form5Example1" class="form-control" name="nik" required/>
</div>
<div class="form-outline mb-4">
<label class="form-label" for="form5Example1">NO HP</label>
<input type="text" id="form5Example1" class="form-control" name="no_hp" required/>
</div>
<div class="row">
<div class="col-xs-4">
<input class="btn btn-block bg-pink waves-effect" type="submit" name="signup" value="DAFTAR">
</div>
</div>
<div class="m-t-25 m-b--5 align-center">
<a href="login.php">Sudah terdaftar Silahkan Login?</a>
</div>
</form>
</div>
</div>
</div>
<!-- Jquery Core Js -->
<script src="plugins/jquery/jquery.min.js"></script>
<!-- Bootstrap Core Js -->
<script src="plugins/bootstrap/js/bootstrap.js"></script>
<!-- Waves Effect Plugin Js -->
<script src="plugins/node-waves/waves.js"></script>
<!-- Validation Plugin Js -->
<script src="plugins/jquery-validation/jquery.validate.js"></script>
<!-- Custom Js -->
<script src="js/admin.js"></script>
</body>