39 lines
1.8 KiB
PHP
39 lines
1.8 KiB
PHP
<div class="modal fade" tabindex="-1" role="dialog" id="create_modal">
|
|
<div class="modal-dialog modal-dialog-centered" role="document">
|
|
<div class="modal-content">
|
|
<div class="modal-header">
|
|
<h5 class="modal-title">Tambah Data</h5>
|
|
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
|
|
<span aria-hidden="true">×</span>
|
|
</button>
|
|
</div>
|
|
<form action="/pasien" method="post" id="create_data_form">
|
|
@csrf
|
|
<div class="modal-body">
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1">Nama</label>
|
|
<input type="text" class="form-control" name="name" aria-describedby="emailHelp" placeholder="Enter name" required>
|
|
</div>
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1">Tanggal Lahir</label>
|
|
<input type="date" class="form-control" name="birth" aria-describedby="emailHelp" required>
|
|
</div>
|
|
<div class="form-group">
|
|
<label for="exampleInputEmail1">Jenis Kelamin</label>
|
|
<select name="gender" class="form-control" required>
|
|
<option value="">Pilih Jenis Kelamin</option>
|
|
<option value="Laki-Laki">Laki-Laki</option>
|
|
<option value="Perempuan">Perempuan</option>
|
|
</select>
|
|
</div>
|
|
</div>
|
|
<div class="modal-footer bg-whitesmoke br">
|
|
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
|
|
<button type="submit" class="btn btn-primary">Save changes</button>
|
|
</div>
|
|
</form>
|
|
|
|
</div>
|
|
</div>
|
|
</div>
|