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formulir.html
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<!DOCTYPE html>
<html lang="id">
<head>
<title>Dokterku - Formulir</title>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" href="css/bootstrap.min.css">
<link rel="stylesheet" href="css/style.css">
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css">
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="js/bootstrap.min.js"></script>
</head>
<body>
<nav class="navbar sticky-top navbar-expand-lg navbar-light bg-white py-3 px-5" >
<a href="index.html" class="navbar-brand text-uppercase text-primary" style="font-weight: bold;"><img class="mr-3" src="img/logoku.png" width="30" height="30" alt="LogoDokterku">Dokterku</a>
<button class="navbar-toggler" type="button" data-toggle="collapse" data-target="#navbarNav" aria-controls="navbarNav" aria-expanded="false" aria-label="Toggle navigation">
<span class="navbar-toggler-icon"></span>
</button>
<div class="collapse navbar-collapse" id="navbarNav" >
<ul class="nav navbar-nav ml-auto" >
<li class="nav-item active">
<a class="nav-link text-primary" href="index.html">Home <span class="sr-only">(current)</span></a>
</li>
<li class="nav-item" >
<a class="nav-link text-primary" href="artikel.html">Artikel</a>
</li>
<li class="nav-item">
<a class="nav-link text-primary" href="dokter.html">Dokter</a>
</li>
<li class="nav-item" id="usernav">
</li>
</ul>
</div>
</nav>
<section class="py-3">
<div class="container mt-4 align-items-center ">
<h2 class="text-primary text-center">Formulir Data</h2>
<hr class="pb-4" style="width: 98%">
<div class="col-md-12 col-lg-12 ml-auto">
<form action="chat.html">
<div class="row">
<div class="form-group col-lg-12 mb-4 ">
<label> <span class="label text-primary "> Nama Lengkap </span></label>
<input type="text" name="nama" placeholder="Nama Lengkap (cth : Natanael Yulius)" class="form-control bg-white py-4 border-md">
</div>
<div class="from-group col-lg-12 mb-4">
<label> <span class="label text-primary"> Jenis Kelamin </span></label><br>
<label class="radio-inline mr-3"><input class="mr-2" type="radio" name="gender" value="laki" checked>Laki Laki</label>
<label class="radio-inline"><input class="mr-2" type="radio" name="gender" value="perempuan">Perempuan</label>
</div>
<div class="form-group col-lg-12 mb-4">
<label> <span class="label text-primary"> Alamat Email </span></label>
<input type="email" name="email" placeholder="Email (cth : [email protected])" class="form-control bg-white py-4 border-md">
</div>
<div class="form-group col-lg-12 px-0">
<label> <span class="label text-primary ml-3"> No Telp </span></label>
<div class="input-group col-lg-12 mb-4">
<div class="input-group-prepend">
<span class="input-group-text bg-white px-4 border-md border-right-0">
<b>+62</b>
</span>
</div>
<input type="tel" name="telphone" placeholder="No Telp (cth : 89501784227)" class="form-control bg-white border-md py-4 pl-3">
</div>
</div>
<div class="form-group col-lg-12 mb-4">
<label> <span class="label text-primary"> Alamat Lengkap </span></label>
<textarea class="form-control bg-white border-md" rows="3" placeholder="Masukkan Alamat (cth : Jln. Baru Sidorejo Lor No 15 Salatiga)"></textarea>
</div>
<hr>
<div class="form-group col-lg-12 mb-4">
<div class="card">
<div class="card-title d-flex flex-wrap align-items-center py-3 px-3">
<img src="img/doctor.jpg" class="rounded-circle mx-3" style="height: 75px; width: 75px"> <p> <b>Salma Dias Saraswati S.Psi, M.Psi, Psikolog</b> <br> Psikolog Klinis Anak dan Remaja</p>
</div>
<div class="card-body">
<div class="col-lg-12 col-md-12 col-xs-12 col-sm-12 d-flex" style="justify-content: space-between;">
<b class="text-primary">Harga Konsultasi 30 Menit : </b>
<p>25.000</p>
</div>
<div class="col-lg-12 col-md-12 col-xs-12 col-sm-12 d-flex" style="justify-content: space-between;">
<b class="text-primary">Diskon Pengguna baru : </b>
<p class="text-danger">- 25.000</p>
</div>
<div class="col-lg-12 col-md-12 col-xs-12 col-sm-12 d-flex flex-wrap align-items-center" style="justify-content: space-between;">
<button type="button" class="btn btn-outline-success">DOKTERKUNEW1</button>
<small class="text-success"> Berhasil dipakai</small>
</div>
<hr>
<div class="col-lg-12 col-md-12 col-xs-12 col-sm-12 d-flex" style="justify-content: space-between;">
<b class="text-primary">Yang Harus dibayar : </b>
<p>0</p>
</div>
</div>
</div>
</div>
<div class="form-group col-lg-12 mx-auto mb-0">
<a href="chat.html" type="button" class="btn btn-outline-primary btn-block py-3">
<span class="font-weight-bold">Konfirmasi Data</span>
</a>
</div>
</div>
</form>
</div>
</div>
</div>
</section>
<section class="mt-5 pt-3 sticky-bottom footer" >
<div class="container">
<div class="row mb-0">
<div class="col-12 text-center">
<p class="text-white">Dokterku © 2020. Syarat dan Ketentuan Berlaku.</p>
</div>
</div>
</div>
</section>
<script type="text/javascript" src="js/nav.js"></script>
</body>
</html>