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register-form.php
executable file
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register-form.php
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<?php
session_start();
?>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>Electronic Medical Information System (EMIS) - Registration</title>
<link href="css/styles.css" rel="stylesheet" type="text/css" />
</head>
<body bgcolor="#aaaaff">
<center><h1 style="color: white; margin-top: 50px;">Registration</h1></center>
<div style="width: 400px; margin-left: auto; margin-right: auto;">
<div class="login_box">
<center>
<img src="img/logo.png" alt="Electronic Medical Information System" />
</center>
<div>
<script type="text/javascript">
function submitform()
{
document.forms["loginForm"].submit();
}
</script>
<form id="loginForm" name="loginForm" method="post" action="register-exec.php">
<center><p><b>Welcome to the Electronic Medical Information System. Login or register using the form below.</b></p></center>
<?php
if (isset($_SESSION['ERRMSG_ARR']) && is_array($_SESSION['ERRMSG_ARR']) && count($_SESSION['ERRMSG_ARR']) > 0) {
echo '<ul class="err">';
foreach ($_SESSION['ERRMSG_ARR'] as $msg) {
echo '<li>', $msg, '</li>';
}
echo '</ul>';
unset($_SESSION['ERRMSG_ARR']);
}
?>
<div class="dashed_line"></div>
<table width="300" border="0" align="center" cellpadding="2" cellspacing="0">
<tr>
<th>First Name </th>
<td><input name="fname" type="text" class="textfield" id="fname" /></td>
</tr>
<tr>
<th>Last Name </th>
<td><input name="lname" type="text" class="textfield" id="lname" /></td>
</tr>
<tr>
<th>Birthdate (MMDDYYYY) </th>
<td><input name="bday" type="date" class="textfield" id="bday" /></td>
</tr>
<tr>
<th>E-Mail </th>
<td><input name="email" type="text" class="textfield" id="email" /></td>
</tr>
<tr>
<th>SSN: </th>
<td><input name="ssn" type="text" class="textfield" id="ssn" /></td>
</tr>
<tr>
<th width="124">Username</th>
<td width="168"><input name="login" type="text" class="textfield" id="login" /></td>
</tr>
<tr>
<th>Password</th>
<td><input name="password" type="password" class="textfield" id="password" /></td>
</tr>
<tr>
<th>Confirm Password </th>
<td><input name="cpassword" type="password" class="textfield" id="cpassword" /></td>
</tr>
<tr>
<th>Type</th>
<td>
<select name="type">
<option value="patient">Patient</option>
<option value="nurse">Nurse</option>
<option value="doctor">Doctor</option>
<option value="admin">Admin</option>
</select>
</td>
</tr>
<tr>
<td> </td>
<td><a class="black_button" href="javascript: submitform()"><span>Register</span></a></td>
</tr>
</table>
</form>
</div>
</div>
</div>
</body>
</html>