ok

Mini Shell

Direktori : /proc/self/root/home/keydecors/public_html/ca/admin/app/
Upload File :
Current File : //proc/self/root/home/keydecors/public_html/ca/admin/app/patients_profile.php

<!DOCTYPE html>
<html lang="en">

<head>
  <!-- Required meta tags -->
  <meta charset="utf-8">
  <meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
  <title>Purple Admin</title>
  <!-- plugins:css -->
  <link rel="stylesheet" href="vendors/iconfonts/mdi/css/materialdesignicons.min.css">
  <link rel="stylesheet" href="vendors/css/vendor.bundle.base.css">
  <!-- endinject -->
  <!-- plugin css for this page -->
  <!-- End plugin css for this page -->
  <!-- inject:css -->
  <link rel="stylesheet" href="css/style.css">
  <!-- endinject -->
  <link rel="shortcut icon" href="images/favicon.png" />
</head>
<?php 

$sa = mt_rand(); 

?>
<body>
  <div class="container-scroller">
    <!-- partial:../../partials/_navbar.html -->
    <nav class="navbar default-layout-navbar col-lg-12 col-12 p-0 fixed-top d-flex flex-row">
      <div class="text-center navbar-brand-wrapper d-flex align-items-center justify-content-center">
        <a class="navbar-brand brand-logo" href="index.html"><img src="images/logo.png" alt="logo"/></a>
        <a class="navbar-brand brand-logo-mini" href="index.html"><img src="images/logo-mini.svg" alt="logo"/></a>
      </div>
      <div class="navbar-menu-wrapper d-flex align-items-stretch">

        <ul class="navbar-nav navbar-nav-right">
          <li class="nav-item nav-profile dropdown">
            <a class="nav-link dropdown-toggle" id="profileDropdown" href="#" data-toggle="dropdown" aria-expanded="false">
              <div class="nav-profile-img">
                       
              </div>
           
            </a>
            <div class="dropdown-menu navbar-dropdown" aria-labelledby="profileDropdown">
            
              <div class="dropdown-divider"></div> <a class="dropdown-item" href="logout_action.php">
                <i class="mdi mdi-logout mr-2 text-primary"></i>
                Signout
              </a>
            </div>
          </li>
          <li class="nav-item d-none d-lg-block full-screen-link">
            <a class="nav-link">
              <i class="mdi mdi-fullscreen" id="fullscreen-button"></i>
            </a>
          </li>
          
         
        
      
        </ul>
        <button class="navbar-toggler navbar-toggler-right d-lg-none align-self-center" type="button" data-toggle="offcanvas">
          <span class="mdi mdi-menu"></span>
        </button>
      </div>
    </nav>
    <!-- partial -->
    <div class="container-fluid page-body-wrapper">
      <!-- partial:../../partials/_sidebar.html -->
<?php include "sidemenu.php";  ?>
      <!-- partial -->
      <div class="main-panel">
        <div class="content-wrapper">
		
		
		        <div class="col-12 grid-margin stretch-card">
              <div class="card">
                <div class="card-body">
                  <h4 class="card-title">Patients Profile</h4>
                  <p class="card-description">
                
                  </p>
                  <form class="forms-sample" action="controller/patients_profile_back.php" method="post">
                     <div class="form-group">
                      <label for="exampleInputName1">Speciality Medicines</label>

                    </div>
                  
                   
                    <div class="form-group">
                      <label for="exampleInputEmail3"> Food Name</label>
                      <input type="text" class="form-control" name="name" id="exampleInputEmail3" placeholder="Name" required>
                    </div>
					
					<div class="form-group">
                      <label for="exampleSelectGender">Food Type</label>
                        <select name="gender" class="form-control" id="exampleSelectGender">
                          <option value="Male">Male</option>
                          <option value="Female">Female</option>
						  <option value="Transgender">Transgender</option>
                        </select>
                      </div>
					  <div class="form-group">
                      <label for="exampleTextarea1">Price</label>
                      <input type="text" class="form-control" name="price" id="exampleInputEmail3" placeholder="Price" required>
                    </div>
						
					
              
                    
                      
                    
                 
                
                    
                    
                         <div class="form-group">
                      <label for="exampleTextarea1">Images</label>
                      <input type="file" class="form-control" name="remindate"   >
                    </div>
                   
                    <button type="submit" class="btn btn-gradient-primary mr-2">Submit</button>
                    
                  </form>
                </div>
              </div>
            </div>
		
		
        </div>
        <!-- content-wrapper ends -->
        <!-- partial:../../partials/_footer.html -->
        <footer class="footer">
          <div class="d-sm-flex justify-content-center justify-content-sm-between">
            <span class="text-muted text-center text-sm-left d-block d-sm-inline-block">Copyright © 2017 <a href="https://www.bootstrapdash.com/" target="_blank">Bootstrap Dash</a>. All rights reserved.</span>
            <span class="float-none float-sm-right d-block mt-1 mt-sm-0 text-center">Hand-crafted & made with <i class="mdi mdi-heart text-danger"></i></span>
          </div>
        </footer>
        <!-- partial -->
      </div>
      <!-- main-panel ends -->
    </div>
    <!-- page-body-wrapper ends -->
  </div>
  <!-- container-scroller -->
  <!-- plugins:js -->
  <script src="vendors/js/vendor.bundle.base.js"></script>
  <script src="vendors/js/vendor.bundle.addons.js"></script>
  <!-- endinject -->
  <!-- Plugin js for this page-->
  <!-- End plugin js for this page-->
  <!-- inject:js -->
  <script src="js/off-canvas.js"></script>
  <script src="js/misc.js"></script>
  <!-- endinject -->
  <!-- Custom js for this page-->
  <!-- End custom js for this page-->
</body>

</html>

Zerion Mini Shell 1.0