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patient_request.php
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patient_request.php
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<!DOCTYPE html>
<html lang="en" dir="ltr">
<head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<title>Book New Consultation - Rx Clinic</title><!-- Prevent the demo from appearing in search engines -->
<meta name="robots" content="noindex"><!-- Simplebar -->
<link type="text/css" href="assets/vendor/simplebar.min.css" rel="stylesheet"><!-- App CSS -->
<link type="text/css" href="assets/css/app.css" rel="stylesheet">
<link type="text/css" href="assets/css/app.rtl.css" rel="stylesheet"><!-- Material Design Icons -->
<link type="text/css" href="assets/css/vendor-material-icons.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-material-icons.rtl.css" rel="stylesheet">
<!-- Font Awesome FREE Icons -->
<link type="text/css" href="assets/css/vendor-fontawesome-free.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-fontawesome-free.rtl.css" rel="stylesheet"><!-- ion Range Slider -->
<link type="text/css" href="assets/css/vendor-ion-rangeslider.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-ion-rangeslider.rtl.css" rel="stylesheet"><!-- Flatpickr -->
<link type="text/css" href="assets/css/vendor-flatpickr.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr.rtl.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr-airbnb.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr-airbnb.rtl.css" rel="stylesheet"><!-- Vector Maps -->
<link type="text/css" href="assets/vendor/jqvmap/jqvmap.min.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-ion-rangeslider.rtl.css" rel="stylesheet"><!-- Flatpickr -->
<link type="text/css" href="assets/css/vendor-flatpickr.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr.rtl.css" rel="stylesheet">
<link type="text/css" href="assets/css/vendor-flatpickr-airbnb.css" rel="stylesheet">
</head>
<body class="layout-default">
<div class="preloader"></div>
<div class="mdk-drawer-layout js-mdk-drawer-layout" data-push data-responsive-width="992px" data-fullbleed>
<div class="mdk-drawer-layout__content">
<!-- Header Layout -->
<div class="mdk-header-layout js-mdk-header-layout" data-has-scrolling-region>
<!-- Header -->
<div id="header" class="mdk-header js-mdk-header m-0" data-fixed data-effects="waterfall"
data-retarget-mouse-scroll="false">
<div class="mdk-header__content">
<div class="navbar navbar-expand-sm navbar-main navbar-light bg-white pr-0" id="navbar"
data-primary>
<div class="container-fluid p-0">
<!-- Navbar toggler --><button
class="navbar-toggler navbar-toggler-custom d-lg-none d-flex mr-navbar"
type="button" data-toggle="sidebar"><span
class="material-icons">short_text</span></button><!-- Navbar Brand --><a
href="#" class="navbar-brand flex "><span>BOOK NEW CONSULTATION</span></a>
<ul class="nav navbar-nav d-none d-md-flex">
<li class="nav-item dropdown"><a href="#notifications_menu"
class="nav-link dropdown-toggle" data-toggle="dropdown"
data-caret="false"><i
class="material-icons nav-icon navbar-notifications-indicator">notifications</i></a>
<div id="notifications_menu"
class="dropdown-menu dropdown-menu-right navbar-notifications-menu">
<div class="dropdown-item d-flex align-items-center py-2"><span
class="flex navbar-notifications-menu__title m-0">Notifications</span><a
href="javascript:void(0)" class="text-muted"><small>Clear
all</small></a></div>
<div class="navbar-notifications-menu__content" data-simplebar>
<div class="py-2">
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm"
style="width: 32px; height: 32px;"><img
src="assets/images/profilew.png" alt="Avatar"
class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> approved your <a
href="">consultation appointment.</a><br><small class="text-muted">1
hr
ago</small></div>
</div>
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm"
style="width: 32px; height: 32px;"><img
src="assets/images/profilew.png" alt="Avatar"
class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> requested to reschedule your <a
href="">consultation appointment.</a><br><small class="text-muted">1
hr
ago</small></div>
</div>
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm"
style="width: 32px; height: 32px;"><img
src="assets/images/profilew.png" alt="Avatar"
class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> cancelled your <a
href="">consultation appointment.</a><br><small class="text-muted">1
day
ago</small></div>
</div>
<div class="dropdown-item d-flex">
<div class="mr-3">
<div class="avatar avatar-sm"
style="width: 32px; height: 32px;"><img
src="assets/images/profilew.png" alt="Avatar"
class="avatar-img rounded-circle">
</div>
</div>
<div class="flex"><a href="patient_consultations.php">Dr. Dentist</a> declined your <a
href="">consultation appointment.</a><br><small class="text-muted">3
days
ago</small></div>
</div>
</div>
</div><a href="javascript:void(0);"
class="dropdown-item text-center navbar-notifications-menu__footer">View
All</a>
</div>
</li>
<li class="nav-item"><a href="#events-drawer" data-toggle="sidebar"
class="nav-link d-flex align-items-center"><i
class="material-icons nav-icon">event_note</i><span
class="badge badge-warning text-primary-dark rounded-circle badge-notifications">1</span></a>
</li>
</ul>
<div class="dropdown"><a href="#" data-toggle="dropdown" data-caret="false"
class="dropdown-toggle navbar-toggler navbar-toggler-company border-left d-flex align-items-center ml-navbar"><span
class="mr-3"><img src="assets/images/profilew.png" width="43" height="43"
alt="avatar"></span></span></a>
<div id="company_menu"
class="dropdown-menu dropdown-menu-right navbar-company-menu">
<div
class="dropdown-item d-flex align-items-center py-2 navbar-company-info py-3">
<span class="mr-3"><img src="assets/images/profilew.png" width="43"
height="43" alt="avatar"></span><span
class="flex d-flex flex-column"><strong style="font-size: 1.125rem;">Ms. User Wan</strong><small
class="text-muted">@msuserwan</small></span>
</div>
<div class="dropdown-divider"></div>
<a class="dropdown-item d-flex align-items-center py-2"
href="patient_myprofile.php"><span class="material-icons mr-2">person</span>My
Profile</a>
<a class="dropdown-item d-flex align-items-center py-2"
href="patient_changepassword.php"><span class="material-icons mr-2">lock</span>Change Password</a>
<!-- <a class="dropdown-item d-flex align-items-center py-2"
href="changepasswordadmin.php"><span
class="material-icons mr-2">lock</span>Change Password</a> -->
</div>
</div>
</div>
</div>
</div>
</div><!-- // END Header -->
<!-- Header Layout Content -->
<div
class="mdk-header-layout__content mdk-header-layout__content--fullbleed mdk-header-layout__content--scrollable page">
<div class="container-fluid page__container">
<div class="card card-body">
<div
class="d-flex flex-column justify-content-center align-items-center mt-2 mb-2 navbar-light">
<a href="index.php" class="navbar-brand text-center mb-2 mr-0"
style="min-width: 0"><img class="navbar-brand-icon"
src="assets/img/rxlogowithname.png" width="320"
alt="Flat"><span></span></a>
</div>
<!-- <div class="d-flex flex-column justify-content-center align-items-center mt-2 mb-2 navbar-light"><a
href="index.php" class="navbar-brand text-center mb-2 mr-0"
style="min-width: 0"><span>DENTAL ZONE PUPQC</span></a>
</div> -->
<!-- <div class="page-separator">
<div class="page-separator__text">with</div>
</div> -->
<div class="page-separator">
<div class="page-separator__text">PERSONAL INFORMATION</div>
</div>
<form action="index.php" novalidate>
<div class="row">
<div class="col">
<div class="form-group"><label class="text-label" for="fname">First Name:</label><input
id="fname" type="text" class="form-control" placeholder="First name" value=""></div>
</div>
<div class="col">
<div class="form-group"><label class="text-label" for="lname">Middle Name:</label><input
id="lname" type="text" class="form-control" placeholder="Middle name" value=""></div>
</div>
<div class="col">
<div class="form-group"><label class="text-label" for="lname">Last Name:</label><input
id="lname" type="text" class="form-control" placeholder="Last name" value=""></div>
</div>
</div>
<div class="row">
<div class="col-lg-6">
<div class="form-group"><label class="text-label"
for="contact">Contact No.:</label><input id="lname" type="text"
class="form-control" placeholder="Contact No." value=""></div>
</div>
</div>
</form>
<div class="page-separator">
<div class="page-separator__text">APPOINTMENT Information</div>
</div>
<form action="index.php" novalidate>
<div class="row">
<div class="col-lg-6">
<div class="form-group"><label class="text-label" for="select01">Personnel:</label>
<select id="select01" data-toggle="select" class="form-control">
<option selected="">Dr. Number Wan</option>
<option>Dr. Number Too</option>
<option>Dr. Number Trii</option>
<option>Dr. Number Fowr</option>
</select>
</div>
</div>
<div class="col">
<div class="form-group"><label class="text-label"
for="flatpickrSample01">Date:</label><input id="flatpickrSample01"
type="text" class="form-control" placeholder="Flatpickr example"
data-toggle="flatpickr" value="today"></div>
</div>
<div class="col">
<div class="form-group"><label class="text-label" for="select01">Service:</label>
<select id="select01" data-toggle="select" class="form-control">
<option selected="">8:00 AM - 9:00 AM</option>
<option>9:00 AM - 10:00 AM</option>
<option>10:00 AM - 11:00 AM</option>
<option>11:00 AM - 12:00 PM</option>
<option>12:00 PM - 1:00 PM</option>
<option>1:00 PM - 2:00 PM</option>
<option>2:00 PM - 3:00 PM</option>
<option>3:00 PM - 4:00 PM</option>
<option>4:00 PM - 5:00 PM</option>
</select>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6">
<div class="form-group"><label class="text-label" for="select01">Service:</label>
<select id="select01" data-toggle="select" class="form-control">
<option>Cardiology</option>
<option>Otolaryngology</option>
<option>Endocrinology</option>
<option>Family Medicine</option>
<option>Gastroenterology</option>
<option>General Dentistry</option>
<option>General Medicine</option>
<option>Internal Medicine</option>
<option>Mental Health</option>
<option>Nephrology</option>
<option>Neurology</option>
<option>Nutritionist-Dietitian</option>
<option>Family Medicine</option>
<option>Obstetrics and Gynecology</option>
<option>Oncology</option>
<option>Opthalmology</option>
<option>Pediatrics</option>
<option>Pulmonology</option>
<option>Rehabilitation Medicine</option>
<option>Rheumatology</option>
<option>Urology</option>
</select>
</div>
</div>
</div>
<div class="modal-footer"><a href="patient_consultations.php"><button type="button" class="btn btn-light"
data-dismiss="modal">Cancel</button></a><a href="#"><button type="button" class="btn btn-dark"
data-toggle="modal"
data-target="#modal-success">Submit</button></a></div>
</form>
</div>
</div>
</div><!-- // END header-layout__content -->
</div><!-- // END header-layout -->
</div><!-- // END drawer-layout__content -->
<!--MODALS-->
<div id="modal-success" class="modal fade" tabindex="-1" role="dialog" aria-hidden="true">
<div class="modal-dialog modal-dialog-centered modal-sm">
<div class="modal-content bg-success">
<div class="modal-body text-center p-4"><i
class="material-icons icon-40pt text-white mb-2">check</i>
<h4 class="text-white">Appointment Requested!</h4>
<p class="text-white mt-3">Your appointment has been submitted.</p><a href="index_patient.php"><button type="button"
class="btn btn-light my-2" data-dismiss="modal">Continue</button></a>
</div><!-- // END .modal-body -->
</div><!-- // END .modal-content -->
</div><!-- // END .modal-dialog -->
</div><!-- // END .modal -->
<div class="mdk-drawer js-mdk-drawer" id="default-drawer" data-align="start">
<div class="mdk-drawer__content">
<div class="sidebar sidebar-dark sidebar-left simplebar" data-simplebar>
<div class="d-flex align-items-center sidebar-p-a border-bottom sidebar-account flex-shrink-0"><a
href="index_patient.php" class="flex d-flex align-items-center text-underline-0 text-body"><span
class="mr-3"><img src="assets/img/rxcliniclogowithoutline.png" width="43" height="43"
alt="avatar"></span><span class="flex d-flex flex-column"><strong
style="font-size: 25px;">Rx Clinic</strong><small
class="text-muted text-uppercase"
style="color: rgba(255,255,255,.54)"></small></span></a>
</div>
<!-- <div
class="sidebar-stats row no-gutters align-items-center text-center border-bottom flex-shrink-0">
<div class="sidebar-stats__col col">
<div class="sidebar-stats__title">Total Patients</div>
<div class="sidebar-stats__value">542</div>
</div>
<div class="sidebar-stats__col col border-left">
<div class="sidebar-stats__title">Total Appointments</div>
<div class="sidebar-stats__value">719</div>
</div>
</div> -->
<!-- <div class="py-4 text-center flex-shrink-0"><a style="min-width: 157px;" href="/signup.php"
class="btn btn-primary">Create <i class="material-icons ml-1">add</i></a></div> -->
<ul class="nav nav-tabs sidebar-tabs flex-shrink-0" role="tablist">
<li class="nav-item"><a class="nav-link active show" id="sm-menu-tab" href="#sm-menu"
data-toggle="tab" role="tab" aria-controls="sm-menu" aria-selected="true">Menu</a></li>
<!-- <li class="nav-item"><a class="nav-link" href="#sm-account" data-toggle="tab">Manage</a></li> -->
<!-- <li class="nav-item"><a class="nav-link" href="#sm-settings" data-toggle="tab">Settings</a></li> -->
</ul>
<div class="tab-content">
<div id="sm-menu" class="tab-pane show active" role="tabpanel" aria-labelledby="sm-menu-tab">
<ul class="sidebar-menu flex">
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_index.php"><i
class="sidebar-menu-icon sidebar-menu-icon--left material-icons">donut_small</i><span
class="sidebar-menu-text">Dashboard</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_consultations.php"><i
class="sidebar-menu-icon sidebar-menu-icon--left material-icons">date_range</i><span
class="sidebar-menu-text">My Consultations</span><span
class="badge badge-warning rounded-circle badge-notifications ml-auto"
style="padding: .1875rem .375rem;">2</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_mydoctors.php"><i
class="sidebar-menu-icon sidebar-menu-icon--left material-icons">person</i><span
class="sidebar-menu-text">My Doctors</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_prescriptions.php"><i
class="sidebar-menu-icon sidebar-menu-icon--left material-icons">description</i><span
class="sidebar-menu-text">Reports</span></a></li>
<li class="sidebar-menu-item"><a class="sidebar-menu-button" href="patient_payments.php"><i
class="sidebar-menu-icon sidebar-menu-icon--left material-icons">payment</i><span
class="sidebar-menu-text">Payment</span></a></li>
</ul>
</div>
</div>
<div class="mt-auto sidebar-p-a sidebar-b-t d-flex flex-column flex-shrink-0">
<a class="sidebar-link mb-2" href="patient_patientreg.php">Register<i class="sidebar-menu-icon ml-2 material-icons icon-16pt">person</i></a>
<a class="sidebar-link" href="landingpagelogin.php"><strong>LOG OUT</strong><i class="sidebar-menu-icon ml-2 material-icons icon-16pt">exit_to_app</i></a>
</div>
</div>
</div>
</div>
</div><!-- // END drawer-layout -->
<div class="mdk-drawer js-mdk-drawer" id="events-drawer" data-align="end">
<div class="mdk-drawer__content">
<div class="sidebar sidebar-light sidebar-left simplebar" data-simplebar>
<small class="text-dark-gray px-3 py-1"><strong>Sunday, 07 Aug</strong></small>
<div class="list-group list-group-flush">
<div class="list-group-item bg-light">
<div class="row">
<div class="col-auto d-flex flex-column"><small>9:00 AM</small><small
class="text-dark-gray">1 hr</small></div>
<div class="col">
<div class="d-flex flex-column flex"><a href="#" class="text-body"><strong
class="text-15pt">Dental Check-up</strong></a><small
class="text-muted d-flex align-items-center"><i
class="material-icons icon-16pt mr-1">person</i>Dr. Dentist</small>
</div>
<div class="avatar-group mt-2">
<div class="avatar avatar-xs"><img src="assets/images/profilew.png" alt="Avatar"
class="avatar-img rounded-circle"></div>
<!-- <div class="avatar avatar-xs"><img
src="assets/images/256_jeremy-banks-798787-unsplash.jpg" alt="Avatar"
class="avatar-img rounded-circle"></div>
<div class="avatar avatar-xs"><img
src="assets/images/256_daniel-gaffey-1060698-unsplash.jpg" alt="Avatar"
class="avatar-img rounded-circle"></div> -->
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div><!-- App Settings FAB -->
<div id="app-settings">
<app-settings></app-settings>
</div><!-- jQuery -->
<script src="assets/vendor/jquery.min.js"></script><!-- Bootstrap -->
<script src="assets/vendor/popper.min.js"></script>
<script src="assets/vendor/bootstrap.min.js"></script><!-- Simplebar -->
<script src="assets/vendor/simplebar.min.js"></script><!-- DOM Factory -->
<script src="assets/vendor/dom-factory.js"></script><!-- MDK -->
<script src="assets/vendor/material-design-kit.js"></script><!-- Range Slider -->
<script src="assets/vendor/ion.rangeSlider.min.js"></script>
<script src="assets/js/ion-rangeslider.js"></script><!-- App -->
<script src="assets/js/toggle-check-all.js"></script>
<script src="assets/js/check-selected-row.js"></script>
<script src="assets/js/dropdown.js"></script>
<script src="assets/js/sidebar-mini.js"></script>
<script src="assets/js/app.js"></script><!-- App Settings(safe to remove) -->
<script src="assets/js/app-settings.js"></script><!-- List.js -->
<script src="assets/vendor/list.min.js"></script>
<script src="assets/js/list.js"></script><!-- Dragula -->
<script src="assets/vendor/dragula/dragula.min.js"></script>
<script src="assets/js/dragula.js"></script>
<script src="assets/vendor/flatpickr/flatpickr.min.js"></script>
<script src="assets/js/flatpickr.js"></script><!-- DateRangePicker -->
<script src="assets/vendor/moment.min.js"></script>
<script src="assets/vendor/daterangepicker.js"></script>
<script src="assets/js/daterangepicker.js"></script>
</body>
</body>
</html>