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BookMedicinesOnline.html
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BookMedicinesOnline.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Online Medicine Booking</title>
</head>
<body>
<h1>Book Your Medicines Online</h1>
<form action="submit_medicine_booking.php" method="post">
<!-- Personal Information Section -->
<fieldset>
<legend>Personal Information</legend>
<label for="full-name">Full Name:</label>
<input type="text" id="full-name" name="full_name" required><br><br>
<label for="email">Email:</label>
<input type="email" id="email" name="email" required><br><br>
<label for="phone">Phone Number:</label>
<input type="tel" id="phone" name="phone" pattern="[0-9]{10}" required><br><br>
<label for="address">Delivery Address:</label><br>
<textarea id="address" name="address" rows="4" cols="40" required></textarea><br><br>
</fieldset>
<!-- Medicine Booking Section -->
<fieldset>
<legend>Medicine Information</legend>
<label for="medicine-name">Medicine Name:</label>
<input type="text" id="medicine-name" name="medicine_name" required><br><br>
<label for="quantity">Quantity:</label>
<input type="number" id="quantity" name="quantity" min="1" required><br><br>
<label for="dosage">Dosage (e.g., 500mg):</label>
<input type="text" id="dosage" name="dosage" required><br><br>
<label for="prescription">Upload Prescription (optional):</label>
<input type="file" id="prescription" name="prescription" accept="image/*,application/pdf"><br><br>
</fieldset>
<!-- Delivery Options Section -->
<fieldset>
<legend>Delivery Options</legend>
<label for="delivery-method">Delivery Method:</label>
<select id="delivery-method" name="delivery_method" required>
<option value="">Select</option>
<option value="standard">Standard Delivery (3-5 days)</option>
<option value="express">Express Delivery (1-2 days)</option>
<option value="same-day">Same Day Delivery</option>
</select><br><br>
<label for="delivery-date">Preferred Delivery Date:</label>
<input type="date" id="delivery-date" name="delivery_date" required><br><br>
</fieldset>
<!-- Payment Information Section -->
<fieldset>
<legend>Payment Information</legend>
<label for="card-number">Card Number:</label>
<input type="text" id="card-number" name="card_number" pattern="[0-9]{16}" required><br><br>
<label for="expiry-date">Expiry Date:</label>
<input type="month" id="expiry-date" name="expiry_date" required><br><br>
<label for="cvv">CVV:</label>
<input type="password" id="cvv" name="cvv" pattern="[0-9]{3}" required><br><br>
</fieldset>
<!-- Submit Button -->
<input type="submit" value="Book Medicines">
</form>
</body>
</html>