<?php include ('header1f.php');?>
<script src="js/jquery-3.5.1.min.js"></script>
<?php 
ob_start();   
session_start();
include ('connection.php') ;

  if (!isset($_SESSION['is_logged_in'])) {
    header("Location:login.php");
    die();
    }
	date_default_timezone_set('Asia/Calcutta');
$today = date("d/m/Y");
$today3 = date("Y-m-d");
$today1 = date("d/m");

?> 
<div class="content-page">
<div class="content">
<div class="container">
<div class="row">
<div class="col-sm-12">
<div class="page-header-title">
<button type="button" class="btn btn-dark  waves-effect waves-light" onclick="location.href='index.php'">BACK </button>
<div class="clearfix"></div>
</div>
</div>
</div>        
        <div class="row">
          <div class="col-md-6">
            <div class="panel panel-primary">
              <div class="panel-heading">
                <h3 class="panel-title">Book An Appointment For Dr. Ashish Gaikwad</h3>
              </div>	
		
			
              <div class="panel-body">
                                    <div class="row"> 

               <form method="post" action="insert_registration.php" enctype="multipart/form-data" onSubmit="return validateForm()">

                        <div class="box-body">
						
							<div class="row">
							
							
							<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">First Name</label>
               					<input type="text" class="form-control" name="first_name" placeholder="First Name" required>
                            </div>
</div></div>

<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">Last Name</label>
               					 <input type="text" class="form-control" name="last_name"  placeholder="Last Name" required>
                            </div>
</div></div>



<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">Mobile No</label>
               				<input type="text" class="form-control" name="mobile_no"  placeholder="Mobile No" required pattern="[0-9]{10}">
                            </div>
</div></div>



<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">City</label>
               					 <input type="text" class="form-control" name="city" placeholder="City" required>
                            </div>
</div></div>



<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">Age</label>
               					<input type="number" class="form-control" name="age" placeholder="Age" required>
                            </div>
</div></div>


<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                                <label for="first_name" class="control-label">Health Issues</label>
               					<textarea name="health_issue" class="form-control" placeholder="Health Issues" required="required"></textarea>
                            </div>
</div></div>

							
							<div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">
							   <div class="form-group">
                               <label for="last_name" class="control-label">Program</label>
                	<select name="tablename"  required class="form-control">
			<option value="">Select</option>
			<option value="kanakveda_registration">Kanakveda Registration</option>
			<option value="height_Increasing_program">Height Increasing Program</option>
			<option value="immunity_booster_program">Immunity Booster Program Registrartion</option>
                  </select>	

                            </div>
</div></div>
                     
					 <div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">       <div class="form-group">

                               <label for="last_name" class="control-label">Reference</label>
                	<select name="reference" class="form-control" required>
		 <option value="">Select Reference</option>
		 <option value="Kanakaveda`s Patient">Kanakaveda's Patient</option>
		 <option value="TV Interview">TV Interview</option>
		 <option value="YouTube">YouTube</option>
		 <option value="Relative">Relative</option>
		 </select>
                            </div></div></div>
							
								 <div class="col-sm-12 col-xs-12">
                                            <div class="m-t-20">       <div class="form-group">

<input type="hidden" name="doctor_id" value="1">
                               <label for="last_name" class="control-label">You want to Consult Dr. Ashish</label><br />
                	<input type="radio" name="how_to_consult" id="rd1"  value="Online">
              <label for="rd1" style="color:#000000">Online</label><br>
              <input type="radio" name="how_to_consult" id="rd2" value="1">
              <label for="rd2" style="color:#000000">In Person at Kanakaveda Clinic - Bandra</label><br>
			  <input type="radio" name="how_to_consult" id="rd3" value="2">
              <label for="rd3" style="color:#000000">In Person at Kanakaveda Clinic - Vasai</label>

                            </div></div></div>
							
							
							
							<div class="col-sm-12 col-xs-12" id="business" >
<div class="form-group">
<label class="form-label" for="mobno">Appointment Date:</label>
<input type="text" class="form-control" id="datepicker" name="appointment_date">
<script>
$(".dt1").datepicker({
inline: true,
minDate: 0,

nextText: '?',
prevText: '?',
showOtherMonths: true,
changeMonth: true,
changeYear: true,
dateFormat: 'yy-mm-dd',
dayNamesMin: ['Sun', 'Mon', 'Tue', 'Wed', 'Thu', 'Fri', 'Sat'],
showAnim: "slide"

});
</script>
</div>
</div>
<div class="col-sm-12 col-xs-12">
<div class="form-group">
<label class="form-label" for="mobno">Time:</label>
<input type="time" class="form-control"  name="appointment_time" >
</div>
</div>

							
					<div class="col-sm-12 col-xs-12">
<div class="form-group"  id="city">

</div>
</div>
</div>
		
							</div>
							
							
							
							
                            
						
							
							
                            <div class="col-sm-12 col-xs-12">
                                           
                                            <div class="m-t-20">
                                                    <div class="form-group">
                                                        <div>
                                                            <button type="submit" class="btn btn-primary waves-effect waves-light" style="float:right"> Submit </button>
							
															
                                                           
                                                        </div>
                                                    </div>
                                               
                                            </div>
                                        </div>

</div>

                    </form></div></div>
									
                                        
												
													
<script>
        $(document).ready(function() {
           
			
			
            $("#datepicker").on('change', function() {
                var stateid = $(this).val();
                $.ajax({
                    method: "POST",
                    url: "appointments1.php",
                    data: {
                        sid: stateid
                    },
                    datatype: "html",
                    success: function(data) {
                        $("#city").html(data);

                    }

                });
				
				});
				
		
        });
    </script>


													
                                                    
                                        
                              </div>
            </div>
          </div>
      </div>
    </div>
   	<?php include 'footer1a.php';?>
