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klantaanmaken.php
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klantaanmaken.php
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<!DOCTYPE html>
<html lang="en">
<head style="">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" type="text/css" href="style.css">
<link href="datetimepicker/sample in bootstrap v2/bootstrap/css/bootstrap.min.css" rel="stylesheet" media="screen">
</head>
<body>
<?php include 'navbar_apotheker.php'; ?>
<div>
<h1 style="text-align: center;">Maak hier uw patiënt aan</h1>
</div>
<div class="form" style="margin-left:43.5%; text-align: center">
<form id="klantaanmaken" class="table" method="post" action="klantaanmaken_parse.php" ;>
<table>
<tr>
<br>
<td>Patiënt naam<br><hr></td></tr>
<tr><td><input type="naam" name="naam"></td></tr>
<tr>
<td>Verzekeringsnummer<br><hr></td></tr>
<tr><td><input type="verzekeringsnummer" name="verzekeringsnummer"></td>
</tr>
<tr>
<td>E-Mail<br><hr></td></tr>
<tr><td><input type="Email" name="Email"></td>
</tr>
<tr>
<td>geboorteplaats<br><hr></td></tr>
<tr><td><input type="geboorteplaats" name="geboorteplaats"></td>
</tr>
<tr>
<td>adres<br><hr></td></tr>
<tr><td><input type="adres" name="adres"></td>
</tr>
<tr>
<td>postcode<br><hr></td></tr>
<tr><td><input type="postcode" name="postcode"></td>
</tr>
<tr>
<td>
<div style="margin-top:30px;"><input type="submit" name="klantaanmaken" class="button button1" value="Patiënt Aanmaken"></div></td>
</tr>
</table>
</form>
</div>
</body>
<br><br><br>
<footer>
</footer>
</html>