72 lines
3.5 KiB
PHP
72 lines
3.5 KiB
PHP
<div class="modal fade"
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id="registerModal"
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tabindex="-1"
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aria-labelledby="exampleModalLabel"
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aria-hidden="true"
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>
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<div class="modal-dialog modal-lg modal-dialog-centered">
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<div class="modal-content">
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<div class="modal-header">
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<h1 class="modal-title fs-5" id="exampleModalLabel">Website Cathering RSAB Harapan Kita</h1>
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</div>
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<form id="formRegister">
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<div class="modal-body">
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<div class="mb-3">
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<h5>Selamat Datang Di Website Cathering RSAB Harapan Kita, <br>
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Bantu Kami Menemukan Referensi Makanan Terbaik untuk Kesehatan Anda.</h5>
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</div>
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<div class="mb-3">
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<label for="exampleInputEmail1" class="form-label">Apakah Anda Seorang</label>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_customer" id="radio_karyawan" value="Karyawan RSAB Harapan Kita" required>
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<label class="form-check-label" for="radio_karyawan" >
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Karyawan RSAB Harapan Kita
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_customer" id="radio_kp" value="Keluarga Pasien / Penunggu Pasien" required>
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<label class="form-check-label" for="radio_kp">
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Keluarga Pasien / Penunggu Pasien
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_customer" id="radio_public" value="Masyarakat Umum" required>
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<label class="form-check-label" for="radio_public">
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Masyarakat Umum
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</label>
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</div>
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</div>
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<div class="mb-3">
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<label for="exampleInputPassword1" class="form-label">Nama Anda ?</label>
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<input type="text" class="form-control" name="nama_customer" id="nama_customer" required>
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</div>
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<div class="mb-3">
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<label for="exampleInputPassword1" class="form-label">Jenis Kelamin ?</label>
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<select class="form-select" aria-label="Default select example" name="jenis_kelamin_customer" id="jenis_kelamin_customer" required>
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<option value="" selected disabled>Pilih Jenis Kelamin</option>
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<option value="Laki-laki">Laki Laki</option>
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<option value="Perempuan">Perempuan</option>
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</select>
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</div>
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<div class="mb-3">
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<label class="form-label">Tanggal Lahir</label>
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<input type="date" class="form-control" name="tanggal_lahir" id="tanggal_lahir">
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</div>
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<div class="mb-3">
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<label for="exampleInputPassword1" class="form-label">Tinggi Badan ?</label>
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<input type="number" class="form-control" name="tinggi_badan_customer" id="tinggi_badan_customer">
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</div>
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<div class="mb-3">
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<label for="exampleInputPassword1" class="form-label">Berat Badan ?</label>
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<input type="number" class="form-control" name="berat_badan_customer" id="berat_badan_customer">
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</div>
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</div>
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<div class="modal-footer">
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<button type="submit" class="btn btn-primary">Lanjutkan</button>
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</div>
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</form>
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</div>
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</div>
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</div>
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