📄 docreg.html
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<HTML>
<HEAD>
<TITLE>DOCTOR'S REGISTRATION </TITLE>
</HEAD>
<BODY bgcolor="sky blue">
<CENTER>
<font size=7 face="arial black" color="red">+</font> <b><font size=6 color="green"><u>Doctor's Registration Form</u></font></b> <font size=7 face="arial black" color="red">+</font>
<TABLE >
<tr>
<td><b>UserId :</b></td>
<td><INPUT type="text" name=uid size=20></td>
</tr>
<TR><TD><B>Doctor Name :</B></TD>
<td><INPUT TYPE="text" NAME="name" size =20></td>
</tr>
<tr>
<TD><B>Age:</B></TD>
<TD><INPUT TYPE="text" NAME="age" size=20></TD>
</TR>
<TR>
<TD><B>Qualification(s)</TD>
</tr>
<tr>
<td><b>(use , as seperator):</b></td>
<TD><INPUT TYPE="text" NAME="qual" size=20></TD>
</tr>
<tr>
<TD><B>Specialization: </TD>
<TD><INPUT TYPE="text" NAME="spec" size=20></TD></B>
</TR>
<tr>
<td><b>Experience:</b></td>
<td><select name="exp">
<option >01
<option >02
<option >03
<option >04
<option >05
<option >06
<option >07
<option >08
<option >09
<option >10
<option >11
<option >12
<option >13
<option >14
<option >15
<option >16
<option >17
<option >18
<option >19
<option >20
</select>
</td>
</tr>
<tr>
<td><b>Achievements</b></td>
<td><textarea name="achieve" rows=3 cols=14></textarea></td>
</tr>
<TR>
<TD><B>House No.:</TD>
<TD><input type="text" name=hno size=20></TD>
</TR>
<tr>
<td><b>Street:</td>
<td><input type="text" name=str size=20></td>
</tr>
<TR>
<TD><B>City:</TD>
<TD><INPUT TYPE="text" NAME="city" size=20></TD>
<TD><B>State</TD>
<TD><INPUT TYPE="text" NAME="state" size=20></TD>
</TR>
<tr>
<td><b>Country:</td>
<td><input type="text" name="country" size=20></td>
<TD><b>Zip Code:</td>
<td><input type="text" name="zcode" size=20></td>
</tr>
<TR>
<TD><B>Phone(Workplace):</TD>
<TD><INPUT TYPE="text" NAME="phone" size=20></TD>
<td><b>Phone(Residence):</td>
<td><input type="text" name="rphone" size=20></td>
</tr>
<TR>
<TD><B>Mobile</TD>
<TD><INPUT TYPE="text" NAME="mobile" size=20></TD>
<TD><B>Fax</TD>
<TD><INPUT TYPE="text" NAME="fax" size=20></TD>
</tr>
<tr>
<TD><B>E-mail Id</TD>
<TD><INPUT TYPE="text" NAME="email" size=20></TD>
</TR>
<tr>
<td><b>Available Timings:</b></td>
<td><input type="text" name="atime" size=20></td>
</tr>
<TR>
<TD><B>Hospital(s)/Clinic(s) Working for:</TD>
</TR><BR>
<TR>
<TD><B>1.Hospital Name :</B></TD>
<td><INPUT TYPE="text" NAME="name" size =20></td>
</tr>
<TR>
<TD><B>House No.:</TD>
<TD><input type="text" name=h1hno size=20></TD>
</TR>
<tr>
<td><b>Street:</td>
<td><input type="text" name=h1str size=20></td>
</tr>
<TR>
<TD><B>City:</TD>
<TD><INPUT TYPE="text" NAME="h1city" size=20></TD>
<TD><B>State</TD>
<TD><INPUT TYPE="text" NAME="h1state" size=20></TD>
</TR>
<tr>
<td><b>Country:</td>
<td><input type="text" name="country" size=20></td>
</tr>
<TR>
<TD><B>Phone1:</TD>
<TD><INPUT TYPE="text" NAME="dw1phone" size=20></TD>
<td><b>Phone2:</td>
<td><input type="text" name="dw2phone" size=20></td>
</tr>
<tr>
<td><B>Fax :</td>
<td><INPUT TYPE="text" NAME="fax" size=20></td>
<td><B>URL :</td>
<td><INPUT TYPE="text" NAME="url" size=20></TD>
</TR>
<TR>
<TD><B>2.Hospital Name :</B></TD>
<td><INPUT TYPE="text" NAME="h2name" size =20></td>
</tr>
<TR>
<TD><B>House No.:</TD>
<TD><input type="text" name=h2hno size=20></TD>
</TR>
<tr>
<td><b>Street:</td>
<td><input type="text" name=h2str size=20></td>
</tr>
<TR>
<TD><B>City:</TD>
<TD><INPUT TYPE="text" NAME="h2city" size=20></TD>
<TD><B>State</TD>
<TD><INPUT TYPE="text" NAME="h2state" size=20></TD>
</TR>
<tr>
<td><b>Country:</td>
<td><input type="text" name="h2country" size=20></td>
</tr>
<TR>
<TD><B>Phone1:</TD>
<TD><INPUT TYPE="text" NAME="h2dw1phone" size=20></TD>
<td><b>Phone2:</td>
<td><input type="text" name="h2dw2phone" size=20></td>
</tr>
<tr>
<td><B>Fax :</td>
<td><INPUT TYPE="text" NAME="h2fax" size=20></td>
<td><B>URL :</td>
<td><INPUT TYPE="text" NAME="h2url" size=20></TD>
</TR>
<TR>
<TD><B>3.Hospital Name :</B></TD>
<td><INPUT TYPE="text" NAME="h3name" size =20></td>
</tr>
<TR>
<TD><B>House No.:</TD>
<TD><input type="text" name=h3hno size=20></TD>
</TR>
<tr>
<td><b>Street:</td>
<td><input type="text" name=h3str size=20></td>
</tr>
<TR>
<TD><B>City:</TD>
<TD><INPUT TYPE="text" NAME="h3city" size=20></TD>
<TD><B>State</TD>
<TD><INPUT TYPE="text" NAME="h3state" size=20></TD>
</TR>
<tr>
<td><b>Country:</td>
<td><input type="text" name="h3country" size=20></td>
</tr>
<TR>
<TD><B>Phone1:</TD>
<TD><INPUT TYPE="text" NAME="h3dw1phone" size=20></TD>
<td><b>Phone2:</td>
<td><input type="text" name="h3dw2phone" size=20></td>
</tr>
<tr>
<td><B>Fax :</td>
<td><INPUT TYPE="text" NAME="h3fax" size=20></td>
<td><B>URL :</td>
<td><INPUT TYPE="text" NAME="h3url" size=20></TD>
</TR>
<TR>
<TD><B>Hospital/Clinic Worked Before:</TD>
</TR><BR>
<TR>
<TD><B>1.Hospital Name :</B></TD>
<td><INPUT TYPE="text" NAME="h1dwbname" size =20></td>
</tr>
<tr>
<td><B>City:</b></td>
<td><input type="text" name="h1dwbcity" size=20></td>
<td><B>State:</b></td>
<td><input type="text" name="h1dwbstate" size=20></td>
</tr>
<tr>
<td><b>Country:</td>
<td><input type="text" name="h1dwbcountry" size=20></td>
<td><B>Phone:</td>
<td><INPUT TYPE="text" NAME="h1dwbphone" size=20></td>
</tr>
<TR>
<TD><B>2.Hospital Name :</B></TD>
<td><INPUT TYPE="text" NAME="h2dwbname" size =20></td>
</tr>
<tr>
<td><B>City:</b></td>
<td><input type="text" name="h2dwbcity" size=20></td>
<td><B>State:</b></td>
<td><input type="text" name="h2dwbstate" size=20></td>
</tr>
<tr>
<td><b>Country:</td>
<td><input type="text" name="h2dwbcountry" size=20></td>
<td><B>Phone:</td>
<td><INPUT TYPE="text" NAME="h2dwbphone" size=20></td>
</tr>
</table></center>
<br><br><br>
<center>
<td><input type="button" value="Submit"></td>
<td><input type="button" value="Back"></td>
<td><input type="button" value="Cancel"></td>
</center>
</BODY>
</HTML>
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