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diagnosis.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Diagnosis</title>
<!-- Latest compiled and minified CSS -->
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/3.4.1/css/bootstrap.min.css">
<!-- jQuery library -->
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<!-- Latest compiled JavaScript -->
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/3.4.1/js/bootstrap.min.js"></script>
</head>
<style>
.register-photo {
background: #f1f7fc;
padding: 100px 100px;
border-radius: 30px;
}
.register-photo .image-holder {
display: table;
width: auto;
background-image: url("image/signup.jpg");
background-size: cover
}
.register-photo .form-container {
display: table;
max-width: 600px;
width: 90%;
margin: 0 auto;
box-shadow: 1px 1px 5px rgba(0, 0, 0, 0.1);
}
.register-photo form {
display: table-row-group;
width: 300px;
background-color: #ffffff;
padding: 50px 50px;
color: #505e6c
}
@media (max-width:991px) {
.register-photo form {
padding: 40px
}
}
.register-photo form h2 {
font-size: 24px;
line-height: 1.5;
margin-bottom: 30px
}
.register-photo form .form-control {
background: transparent;
border: none;
border-bottom: 1px solid #dfe7f1;
border-radius: 0;
box-shadow: none;
outline: none;
color: inherit;
text-indent: 0px;
height: 40px
}
.register-photo form .form-check {
font-size: 13px;
line-height: 20px
}
.register-photo form .btn-primary {
background: green;
border: none;
border-radius: 4px;
padding: 11px;
box-shadow: none;
margin-top: 35px;
text-shadow: none;
outline: none !important
}
.register-photo form .btn-primary:active {
transform: translateY(1px)
}
.register-photo form .already {
display: block;
text-align: center;
font-size: 12px;
color: #6f7a85;
opacity: 0.9;
text-decoration: none
}
</style>
<body style="background-color: #f1f7fc ;">
<div class="register-photo">
<div class="form-container">
<form method="">
<center><h2 class="text-center">Get Child Detail</h2></center>
<div class="form-group"><input class="form-control" type="firstname" name="firstname" placeholder="Enter Name"></div>
<div class="form-group"><label>Enter the Date of birth of Child</label><input class="form-control" type="date" name="dateofbirth" placeholder="Enter Date of birth"></div>
<!-- <a href="#" class="btn btn-danger">Sign Up</a> -->
<button type="submit" class="btn btn-danger" >Get Detail</button>
<!--<div class="form-group"><button class="button" type="submit">Sign Up</button></div>
<a class="already" href="#">Already have an account? Login .</a>-->
<!-- <a class="already" href="#">Already have an account? Login .</a>-->
</form>
<form>
<div class="form-group"><input class="form-control" value="childid" name="firstname" readonly></div>
<div class="form-group">
<label for="diagnosis">Select the diagnosis</label>
<select id="diagnosis" name="diagnosis">
<option value="test1">test1</option>
<option value="test2">test2</option>
<option value="test3">test3</option>
<option value="test4">test4</option>
</select>
</div>
<div class="form-group"><label>Enter the Date of Diagnosis</label><input class="form-control" type="date" name="dateofbirth" placeholder="Enter Date of diagnosis"></div>
<div class="form-group">
<label for="status">Status : </label>
<select id="status" name="status">
<option value="Positive">Positive</option>
<option value="Negative">Negative</option>
</select>
</div>
<button type="submit" class="btn btn-danger" >Submit</button>
</form>
</div>
</div>
</body>
</html>