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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="stylesheet" href="css/style.css">
<link rel="icon" href="assets/img/icon-web.ico" />
<title>TwentySevenMedika</title>
<style>
header nav {
align-items: center !important;
background-color: #4fc0ec !important;
box-shadow: 0 2px 4px 0 rgba(0, 0, 0, 0.2) !important;
color: #fff !important;
height: 90px !important;
display: flex !important;
justify-content: space-between !important;
position: fixed !important;
top: 0 !important;
width: 100% !important;
}
header nav .logo {
display: flex !important;
flex-direction: row !important;
font-family: 'Quicksand ', sans-serif !important;
letter-spacing: 1px !important;
align-items: center !important;
margin-left: 30px !important;
}
.logo-company {
height: 80px !important;
}
.label-company {
margin-left: 30px !important;
font-size: 2rem !important;
font-family: 'Quicksand', sans-serif !important;
font-weight: bold !important;
}
header nav ul {
display: flex !important;
justify-content: space-between !important;
list-style-type: none !important;
width: 35% !important;
margin-right: 50px !important;
z-index: 300 !important;
}
header nav ul li {
font-size: 1.15em !important;
}
header nav ul li a {
color: #fff !important;
transition: all 0.2s ease-in-out !important;
/* font-size: 1.15em; */
padding: 0.5rem 1.5rem !important;
border-radius: 5px !important;
text-decoration: none !important;
}
header nav ul li a:hover {
color: #4fc0ec !important;
background-color: #fff !important;
transition: all 0.2s ease-in-out !important;
}
.menu-toggle {
display: none !important;
flex-direction: column !important;
height: 20px !important;
justify-content: space-between !important;
position: relative !important;
}
.menu-toggle input {
cursor: pointer !important;
height: 28px !important;
left: -6px !important;
opacity: 0 !important;
position: absolute !important;
top: -3px !important;
width: 40px !important;
z-index: 2 !important;
}
.menu-toggle span {
background-color: #fff !important;
border-radius: 3px !important;
display: block !important;
height: 3px !important;
transition: all 0.5s !important;
width: 28px !important;
}
.menu-toggle span:nth-child(2) {
transform-origin: 0 0 !important;
}
.menu-toggle span:last-child {
transform-origin: 0 100% !important;
}
.menu-toggle input:checked ~ span:nth-child(2) {
background-color: #fff !important;
transform: rotate(45deg) translate(-1px, -1px) !important;
}
.menu-toggle input:checked ~ span:nth-child(3) {
opacity: 0 !important;
transform: scale(0) !important;
}
.menu-toggle input:checked ~ span:last-child {
background-color: #fff !important;
transform: rotate(-45deg) translate(-1px) !important;
}
@media screen and (max-width: 1168px) {
header nav ul {
width: 50% !important;
}
.gambar-pertama {
width: 30% !important;
}
}
@media screen and (max-width: 768px) {
header nav ul {
width: 50% !important;
}
.gambar-pertama {
width: 40% !important;
}
}
@media screen and (max-width: 576px) {
header {
width: 100% !important;
z-index: 999 !important;
}
header nav {
justify-content: space-around !important;
z-index: 999 !important;
}
header .menu-toggle,
header nav {
display: flex !important;
z-index: 999 !important;
}
.label-company {
margin: 0 !important;
font-size: 2.5rem !important;
font-family: 'Quicksand', sans-serif !important;
z-index: 999 !important;
}
.logo-company {
display: none !important;
z-index: 999 !important;
}
header nav ul {
z-index: 999 !important;
align-items: center !important;
background-color: #4fc0ec !important;
flex-direction: column !important;
height: 25vh !important;
justify-content: space-evenly !important;
opacity: 0 !important;
position: absolute !important;
left: 0 !important;
top: 70px !important;
transform: translateX(0) !important;
transition: all 2s !important;
width: 100% !important;
border-bottom-left-radius: 40px !important;
border-bottom-right-radius: 40px !important;
/* z-index: 300 !important; */
}
header nav ul li {
padding-top: 5px !important;
/* z-index: 300 !important; */
}
header nav ul li a{
padding-top: 5px !important;
font-size: 2rem !important;
/* z-index: 300 !important; */
}
header nav ul.slide {
opacity: 1 !important;
transform: translateX(100) !important;
transition: all 2s !important;
z-index: 999 !important;
}
.btn-submit {
background-color: #4fc0ec;
/* Green */
width: 70%;
border: none;
border-radius: 10px;
color: #ffffff;
padding: 15px 35px;
text-align: center;
text-decoration: none;
display: inline-block;
font-size: 16px;
align-items: center;
margin-right: 50px;
}
.login-wrapper {
width: 75%;
display: flex;
justify-content: center;
margin-left: 60px;
margin-top: -70px !important;
color: #727272;
margin-bottom: -120px;
align-items: center;
}
.home-pagetiga .home-wrapper {
display: flex;
justify-content: center;
flex-wrap: wrap;
margin-top: -300px;
margin-left: 10px;
}
.footer-page2 {
font-size: 1.2rem !important;
}
}
</style>
</head>
<body class="page-tiga-body">
<!-- header start -->
<header>
<nav>
<div class="logo">
<img class="logo-company" src="assets/img/logo-twentysevenmedika.png" alt="TwentySevenMedika" />
<p class="label-company">TwentySevenMedika</p>
</div>
<ul>
<li><a href="index.html">Home</a></li>
<li><a href="about.html">About Us</a></li>
<li><a href="schedules.html">Schedule</a></li>
<li><a href="#appointment" hidden>Appointment</a></li>
</ul>
<div class="menu-toggle">
<input type="checkbox" />
<span></span>
<span></span>
<span></span>
</div>
</nav>
</header>
<!-- header end -->
<section class="home-pagetiga" id="home">
<div class="container home-wrapper">
<div class="content-left">
<h1 class="heading">Patient Information</h1>
<p class="subheading">Please fill the form below to book appointment</p>
</div>
</div>
<div class="content-right">
</div>
</section>
<div class="login-wrapper">
<form style="z-index: 5;" action="receipt.html">
<div>
<label for="name" class="label">Full Name</label>
<input type="text" name="name" class="tumpul-outline-biru" required>
</div>
<div>
<label for="email" class="label">E-mail</label>
<input type="email" name="email" class="tumpul-outline-biru" required>
</div>
<div>
<label class="label" style="margin-bottom: 5px;">Gender</label>
<label class="radio-container" style="margin-right: 30px;">Male
<input type="radio" name="gender" class="blue-radio" required>
<span class="checkmark"></span>
</label>
<label class="radio-container">Female
<input type="radio" name="gender" class="blue-radio">
<span class="checkmark"></span>
</label>
</div>
<div>
<label class="label">Date of Birth</label>
<input type="date" class="tumpul-outline-biru" required>
</div>
<div>
<label class="label">Reason for the Visit (Please describe your symptoms or
reason for the appointment)</label>
<input type="text" class="tumpul-outline-biru">
</div>
<!-- id sebelumnya cheklist diganti jadi confirm biar bisa di klik tulisannya-->
<div style="margin-top: 20px;">
<input type="checkbox" id="confirm" required name="confirm"
>
<label for="confirm"> I confirm that the information provide is accurate. </label><br>
</div>
<div style="margin-top: 20px;">
<input type="checkbox" id="consent" required name="consent">
<label for="consent">I consent that to the appointment
and the sharing of my medical information with the chosen docter.</label>
<br>
</div>
<div style="margin-top: 50px; margin-bottom: 50px">
<div class="book-btn">
<a href="receipt.html">
<input src="receipt.html" type="submit" value="Book" class="btn-submit"></input>
</a>
</div>
</div>
</form>
</div>
<footer class="footer-page2"><p>All Right Reserved © Created by Group 27 Section Semarang</p></footer>
<script src="js/script.js"></script>
</body>
=======
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<link rel="stylesheet" href="css/style.css">
<link rel="icon" href="assets/img/icon-web.ico" />
<title>Patient Form</title>
</head>
<body>
<header>
<nav>
<div class="logo">
<a href="index.html">
<img class="logo-company" src="assets/img/logo-twentysevenmedika.png" alt="TwentySevenMedika" />
</a>
<p class="label-company">TwentySevenMedika</p>
</div>
<ul>
<li><a class="border-item-navbar" href="index.html">Home</a></li>
<li><a class="border-item-navbar" href="about.html">About Us</a></li>
<li><a class="border-item-navbar" href="schedule-general.html">Schedule</a></li>
</ul>
<div class="menu-toggle">
<input type="checkbox" />
<span></span>
<span></span>
<span></span>
</div>
</nav>
</header>
<div class="patientform-wrapper">
<div class="patientform">
<h1>Patient Information</h1>
<p>Please fill the form below to book appointment</p>
<form style="z-index: 5;" id='patientForm'>
<div>
<label for="name" class="label">Full Name</label>
<input type="text" name="name" class="tumpul-outline-biru" id="inputName" placeholder="Enter full name" required>
</div>
<div>
<label for="email" class="label">E-mail</label>
<input type="email" name="email" class="tumpul-outline-biru" id="inputEmail" placeholder="Enter e-mail address" required>
</div>
<div>
<label class="label" style="margin-bottom: 5px;">Gender</label>
<label class="radio-container" style="margin-right: 30px;">Male
<input type="radio" name="gender" class="blue-radio" value=1 required>
<span class="checkmark"></span>
</label>
<label class="radio-container" >Female
<input type="radio" name="gender" class="blue-radio" value=0>
<span class="checkmark"></span>
</label>
</div>
<div>
<label class="label">Date of Birth</label>
<input type="date" class="tumpul-outline-biru" id="inputDOB" required>
</div>
<div>
<label class="label">Reason for the Visit (Please describe your symptoms or reason for the appointment)</label>
<input type="text" class="tumpul-outline-biru" id="inputReason" placeholder="Ex. Routine check-up" >
</div>
<div style="margin-top: 20px;">
<input type="checkbox" id="confirm" required name="confirm">
<label for="confirm"> I confirm that the information provide is accurate. </label>
<br>
</div>
<div style="margin-top: 20px;">
<input type="checkbox" id="consent" required name="consent">
<label for="consent">I consent that to the appointment and the sharing of my medical information with the chosen doctor.</label>
<br>
</div>
<div class="book-btn">
<!-- <a href="receipt.html"> -->
<input src="receipt.html" type="submit" value="Book" class="btn-submit" id="btn-booking"></input>
<!-- </a> -->
</div>
</form>
</div>
</div>
<footer class="footer-allpage"><p>All Right Reserved © Created by Group 27 Section Semarang</p></footer>
<!-- Add external javascript -->
<script src="js/script.js"></script>
</body>
</html>