?? appform.html
字號:
<html>
<body bgcolor="yellow">
<center>
<font size=6 color="red"><b><u>Appointment Form</u></b></font><br><br>
<table>
<tr>
<td><b>Area:</b></td>
<td>
<select name="area">
<option>Hyderabad
<option>Bangalore
<option>Delhi
</select>
</td>
</tr>
<tr>
<td><b>Hospital Name:</b></td>
<td>
<select name="hname">
<option>NIMS
<option>Apollo
<option>CDR
<option>Osmania
</select>
</td>
</tr>
<tr>
<td><b>Patient Name:</b></td>
<td><input type="text" size=20></td>
</tr>
<tr>
<td><b>E-mail:</b></td>
<td><input type="text" size=20></td>
</tr>
<tr>
<td><b>Address:</b></td>
<td><textarea cols=20 rows=4></textarea></td>
</tr>
<tr>
<td><b>Contact Phone:</b></td>
<td><input type="text" size=20></td>
<td><b>Time to Contact:</b></td>
<td>
<select name="time">
<option>5:30a.m
</select>
</td>
</tr>
<tr>
<td><b>Appointment Date:</b></td>
<td>
<select name="mont">
<option>January
<option>February
<option>March
<option>April
<option>May
<option>June
<option>July
<option>August
<option>September
<option>October
<option>November
<option>December
</select>
</td>
<td>
<SELECT NAME="dy">
<option value=>01
<option value=>02
<option value=>03
<option value=>04
<option value=>05
<option value=>06
<option value=>07
<option value=>08
<option value=>09
<option value=>10
<option value=>11
<option value=>12
<option value=>13
<option value=>14
<option value=>15
<option value=>16
<option value=>17
<option value=>18
<option value=>19
<option value=>20
<option value=>21
<option value=>22
<option value=>23
<option value=>24
<option value=>25
<option value=>26
<option value=>27
<option value=>28
<option value=>29
<option value=>30
<option value=>31
</select>
</td>
<td>
<select name="year">
<option >2001
<option >2002
<option >2003
<option >2004
<option >2005
<option >2006
<option >2007
<option >2008
<option >2009
<option >2010
</select>
</td>
</tr>
<tr>
<td><b>Timings:</b></td>
<td>
<select name="atime">
<option>5:30a.m
</select>
</td>
</tr>
<tr>
<td><b>Prime Complaint:</b></td>
<td><input type="text" size=20></td>
</tr>
<tr>
<td><b>Additional Information about complaint:</b></td>
<td><textarea cols=20 rows=4></textarea></td>
</tr>
<tr>
<td><b>How can we inform you:</b></td>
<td>
<select name="inform">
<option>E-mail
<option>Telephone
<option>Post
</select>
</td>
</tr>
</table>
<br><br>
<input type="button" value="Submit">
<input type="button" value="Back">
<input type="button" value="Cancel">
</center>
</body>
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