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registrasi.html
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registrasi.html
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<!DOCTYPE html>
<html lang="en">
<head>
<!-- basic -->
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<!-- mobile metas -->
<meta name="viewport" content="width=device-width, initial-scale=1">
<meta name="viewport" content="initial-scale=1, maximum-scale=1">
<!-- site metas -->
<title>RSUD Tarutung</title>
<meta name="keywords" content="">
<meta name="description" content="">
<meta name="author" content="">
<!-- bootstrap css -->
<link rel="stylesheet" href="css/bootstrap.min.css">
<!-- style css -->
<link rel="stylesheet" href="css/style.css">
<!-- Responsive-->
<link rel="stylesheet" href="css/responsive.css">
<!-- fevicon -->
<link rel="icon" href="images/icon.jpg" type="image/gif">
<!--ICONFONT CSS-->
<link rel="stylesheet" href="css/icofont.css" media="all">
</head>
<!-- body -->
<body class="main-layout" onload="startTime()">
<!-- loader -->
<div class="loader_bg">
<div class="loader"><img src="images/loading.gif" alt="#" /></div>
</div>
<!-- end loader -->
<!-- header -->
<header>
<!-- header inner -->
<div class="header">
<div class="container">
<div class="row">
<div class="col-xl-3 col-lg-3 col-md-3 col-sm-3 col logo_section">
<div class="full">
<div class="center-desk">
<div class="logo"><a href="index.html">
<img src="images/Logo.png" alt="">
</a> </div>
</div>
</div>
</div>
<div class="col-xl-9 col-lg-9 col-md-9 col-sm-9">
<div class="menu-area">
<div class="limit-box">
<nav class="main-menu">
<ul class="menu-area-main">
<li class="active"> <a href="index.html">Beranda</a> </li>
<li> <a href="registrasi.html">Registrasi</a> </li>
<li> <a href="informasi.html">Informasi</a> </li>
<li> <a href="tentang.html">Tentang</a> </li>
<li></li>
</nav>
</div>
</div>
</div>
</div>
</div>
<!-- end header inner -->
</header>
<!-- end header -->
<!-- Start Pendaftaran -->
<div id="testimonial" class="testimonial">
<div class="container">
<div class="row">
<div class="banner">
<h1><b>Pendaftaran</b></h1>
</div>
</div>
<div class="row">
<div class="col-md-7">
<form class="form-horizontal" name="formPendaftaran" onsubmit="return false" id="FormPendaftaran">
<div class="form-group">
<label class="control-label col-sm-3" for="NamaLengkap">Nama Lengkap</label>
<div class="col-sm-12">
<input type="text" name="nama" class="form-control" id="NamaLengkap" placeholder="Masukan Nama Anda">
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-3" for="Usia">Usia</label>
<div class="col-sm-12">
<input type="number" name="umur" min="0" max="200" class="form-control" id="Usia">
</div>
</div>
<div class="form-group">
<div class="col-sm-12">Poli yang dituju</div>
<div class="col-sm-12">
<select name="Pilih" id="selectPoli" class="nice-select form-control" onfocus='this.size=5;'onblur='this.size=1;' onchange='this.size=1; this.blur();' tabindex="0" required="">
<option class="option wide" value="--Pilih--">--Pilih--</option>
<option class="option wide" value="1">Poli Gigi</option>
<option class="option wide" value="2">Penyakit Bagian Dalam</option>
<option class="option wide" value="3">Poli Umum</option>
<option class="option wide" value="4">Anak dan Kandungan</option>
<option class="option wide" value="5">Poli Mata</option>
<option class="option wide" value="6">Spesialis Saraf dan Kejiwaan</option>
<option class="option wide" value="7">Poli Hemodialsis</option>
<option class="option wide" value="8">Poli THT</option>
</select>
</div>
</div>
<div class="form-group">
<label class="control-label col-sm-12" for="NoKartu">No. Kartu BPJS</label>
<div class="col-sm-12">
<input type="number" class="form-control" id="NoKartu" name="NoKartu">
<caption><h6>*Jika menggunakan kartu BPJS</h6></caption>
</div>
</div>
<div class="form-group">
<div class="col-sm-12">Kategori</div>
<div class="col-sm-12">
<select name="kategori" id="selectKategori" class="form-control" onfocus='this.size=3;'onblur='this.size=1;' onchange='this.size=1; this.blur();' tabindex="0" required="">
<option class="option wide" value="--Pilih--">--Pilih--</option>
<option class="option wide" value="1">BPJS</option>
<option class="option wide" value="2">REGULER</option>
</select>
</div>
</div>
<div class="clear"></div>
<div class="form-group">
<div class="col-sm-5">
<label for="rujukan">Surat Rujukan</label>
</div>
<div class="col-sm-5">
<input type="file" id="rujukan">
</div>
</div>
<div class="form-group">
<div class="col-sm-offset-2 col-sm-10">
<button type="submit" class="btn btn-default" id="tombol_form">Submit</button>
</div>
</div>
</form>
</div>
<div class="col-md-5" id="sukses">
<div class="contact" style="background-color: #A6F6F1;">
<h3>Anda telah didaftarkan</h3>
<div class="row">
<div class="col-md-6 result">
Nama           :
</div>
<div class="col-md-6 result">
<p class="p1"></p>
</div>
<div class="col-md-6 result">
Usia             :
</div>
<div class="col-md-6 result">
<p class="p2"></p>
</div>
<div class="col-md-6 result">
Poli yang dituju   :
</div>
<div class="col-md-6 result">
<p class="p4" id="poli"></p>
</div>
<div class="col-md-6 result">
Kategori         :
</div>
<div class="col-md-6 result">
<p class="p3" id="kategori"></p>
</div>
<div class="col-md-6 result">
No. Antrian      :
</div>
<div class="col-md-6 result">
<p class="p5" id="antrian"></p>
</div>
</div>
</div>
</div>
<div class="clear"></div>
<div>
<h2> </h2>
</div>
<div class="container valign" style="background-color: #A6F6F1;">
<div class="row">
<div class="col-md-12 col-xs-4">
<!-- kontennya -->
<div class="panel panel-default text-center">
<b>Status Terkini</b>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12 col-xs-6">
<!-- kontennya -->
<div class="text-center panel-default">
Sekarang pukul
<div id="txt"></div>
</div>
<div class="col-md-2"></div>
</div>
<div class="col-md-12 text-center panel-default">
Pasien No antrian<div id="pasienAntrian"></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<!-- end Testimonial -->
<!-- footer -->
<footer>
<div class="footer">
<div class="container">
<div class="row">
<div class="col-lg-4 col-md-6 col-sm-12 width">
<i><img src="images/logo2.png"></i>
<div class="address">
<h3> <br> Kami peduli dengan <br> Kesehatan Anda</h3>
</div>
</div>
<div class="col-md-4">
</div>
<div class="col-md-4">
<h1 style="color: white;">Callcenter</h1> <br>
<h3 style="color: white;"> +621274190248 <br>[email protected] <br>Jl. H.Agus Salim No.1 Tarutung
</h3>
</div>
</div>
</div>
<div class="copyright">
<p>Copyright ©2020 All Rights Reserved By Sehatku.id</p>
<div class="clear">
</div>
</div>
</div>
</footer>
<!-- end footer -->z
<!-- Javascript files-->
<script src="js/jquery.min.js"></script>
<script src="js/popper.min.js"></script>
<script src="js/bootstrap.bundle.min.js"></script>
<script src="js/jquery-3.0.0.min.js"></script>
<script src="js/plugin.js"></script>
<!-- sidebar -->
<script src="js/jquery.mCustomScrollbar.concat.min.js"></script>
<script src="js/custom.js"></script>
<script src="js/main.js"></script>
</body>
</html>