MSV FM

Path : /hermes/bosweb/b1705/trinix19.ipage.com/Backup/DoctorsReview/

File Upload :

Current < : /hermes/bosweb/b1705/trinix19.ipage.com/Backup/DoctorsReview/footer.php

<div class="modal fade hide" id="my-modal">
		<form method="post" action="home-save.php">

			<div class="modal-header">
				<button class="close" data-dismiss="modal">&times;</button>
				<h3>Sign Up</h3>
			</div>
			
			<div class="modal-body">
				<div class="row">
					<div class="span2">Doctors Name</div>
					<div class="span2"><input type="text" name="dname" required/></div>
				</div>
				<div class="row">
					<div class="span2">Doctors Location</div>
					<div class="span2"><input type="text" name="dlocation" required/></div>
				</div>
				
				<div class="row" id="spec" >
					<script src="multiselect/chosen/chosen.jquery.js" type="text/javascript"></script>
					<script src="multiselect/chosen/chosen.jquery.js"></script>
					<div class="span2">Select Specialities: </div>
					<div class="span2"><select data-placeholder="" class="chzn-select" multiple tabindex="4"  name="spec[]" id="view">
					  <option value=""></option>
					  <?php
								include('dbconnect.php');
								
								$result=mysql_query("Select type from specialist");
								
									while($row=mysql_fetch_array($result))
										{
							?>
					  <option  value="<?php echo $row[0];?>"><?php echo $row[0]; ?></option>
					  <br />
					  <?php
					 }
					 ?>
					</select></div>
					</div>
				
					<div class="row" id="oth">
						<script src="multiselect/chosen/chosen.jquery.js" type="text/javascript"></script>
						<script src="multiselect/chosen/chosen.jquery.js"></script>
						<div class="span2">Select Symptom: </div>
						<div class="span2">
							<select data-placeholder="" class="chzn-select" multiple  tabindex="4" name="symp[]" id="t">
							<option value=""></option>
							<?php
									
									include('dbconnect.php');
														
									$result=mysql_query("Select type from symptoms");
														
									while($row=mysql_fetch_array($result))
									{
												
								?>
								<option  value="<?php echo $row[0];?>"><?php echo $row[0]; ?></option>
						  <?php
							}
						 ?>
						</select></div>
						<script type="text/javascript"> $(".chzn-select").chosen(); $(".chzn-select-deselect").chosen({allow_single_deselect:true}); </script>
					</div>
				
			
			
				<input type="submit" value="+ Add" class="btn btn-primary" name="addBtn"/>	
			</div>
			</div>
			
	
		
	
	</div>
		
	<!-- JavaScript -->
	
	<script src="js/bootstrap.js"></script>
	<script type="text/javascript">
		$("#my-button").click(function(){
			$("#my-modal").modal();
		});
	</script>

	
</body>
</html>