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<?php
include "db.php";
include "header.php";
include "sidebar.php";
$user_id=$_SESSION['id'];
$a=0;
$stmt=$conn->prepare("SELECT * FROM `new_resume` WHERE `remark`=? AND `user`=?");
mysqli_stmt_bind_param($stmt,"ss",$a,$log_id);
$stmt->execute();
$result=$stmt->get_result();
while($row = $result->fetch_object())
{
$pdf = $row->resume;
$b = $row->id;
}
if (isset($_POST['submit']))
{
$image_no=$_POST['image_no'];
$fname = $_POST['fname'];
$lname = $_POST['lname'];
$email = $_POST['email'];
$contact = $_POST['contact'];
$address= $_POST['address'];
$city=$_POST['city'];
$state = $_POST['state'];
$zipcode = $_POST['zipcode'];
$bloodgroup = $_POST['bloodgroup'];
$height=$_POST['height'];
$weight =$_POST['weight'];
$age= $_POST['age'];
$marital_status =$_POST['marital_status'];
$ip = $_POST['ip'];
$policy_no= $_POST['policy_no'];
$dob =$_POST['dob'];
$emg_contact= $_POST['emg_contact'];
$dr_id=$_POST['dr_id'];
$dr_fname = $_POST['dr_fname'];
$dr_lname= $_POST['dr_lname'];
$nurse_name= $_POST['nurse_name'];
$hospital_reg_no= $_POST['hospital_reg_no'];
$hospital_contact_no = $_POST['hospital_contact_no'];
$hospital_add= $_POST['hospital_add'];
$hospital_email=$_POST['hospital_email'];
$agent_fname = $_POST['agent_fname'];
$agent_lname = $_POST['agent_lname'];
$agent_contact_no=$_POST['agent_contact_no'];
$agent_email = $_POST['agent_email'];
$agent_address = $_POST['agent_address'];
$agent_code=$_POST['agent_code'];
$query = "INSERT INTO insurance(image_no,fname,lname,email,contact,address,city,state,zipcode,bloodgroup,height,weight,age,marital_status,ip,policy_no,dob,emg_contact,dr_id,dr_fname,dr_lname,nurse_name,hospital_reg_no,hospital_add,hospital_contact_no,hospital_email,agent_fname,agent_lname,agent_contact_no,agent_email,agent_address,agent_code)
VALUES ('".$image_no."','".$fname."','".$lname."', '".$email."', '".$contact."','".$address."','".$city."', '".$state."', '".$zipcode."','".$bloodgroup."','".$height."','".$weight."','".$age."', '".$marital_status."', '".$ip."', '".$policy_no."', '".$dob."', '".$emg_contact."', '".$dr_id."', '".$dr_fname."', '".$dr_lname."', '".$nurse_name."', '".$hospital_reg_no."', '".$hospital_add."','".$hospital_contact_no."', '".$hospital_email."', '".$agent_fname."', '".$agent_lname."', '".$agent_contact_no."', '".$agent_email."', '".$agent_address."', '".$agent_code."')";
mysqli_query($conn, $query);
}
?>
<style>
@media(max-width: 600px)
{
.hide{
display: none;
}
.hide1{
display: show;
}
}
@media(min-width: 601px)
{
.hide{
display: show;
}
.hide1{
display: none;
}
}
</style>
<style>
div.scrollmenu {
background-color: white;
overflow: auto;
white-space: nowrap;
}
div.scrollmenu a {
display: inline-block;
color: white;
text-align: center;
padding: 14px;
text-decoration: none;
}
div.scrollmenu a:hover {
background-color: white;
}
.previous {
background-color: #f1f1f1;
color: black;
}
.next {
background-color: #04AA6D;
color: white;
}
.round {
border-radius: 50%;
}
</style>
<main id="main" class="main">
<div class="pagetitle">
<h1>New Form</h1>
<nav>
<ol class="breadcrumb">
<li class="breadcrumb-item"><a href="index.php">Home</a></li>
<li class="breadcrumb-item active">Dashboard</li>
</ol>
</nav>
</div>
<!-- End Page Title -->
<section class="section dashboard">
<div class="row">
<!-- Left side columns -->
<div class="col-lg-12">
<div class="row">
<!-- Sales Card -->
<div class="col-sm-8" >
<div class="card info-card sales-card" style="height: 500px;">
<div class="card-body" style="height: 550px; max-height: 82vh;overflow-y: scroll;">
<div class="card-title">
<h4 style="font-family: Times New Roman;font-size: 19px;"><b> New Form</b></h4>
</div>
<button onclick="zoomIn()" class="btn btn-danger" style="font-size: 10px;">Zoom-In</button>
<button onclick="zoomOut()" class="btn btn-dark" style="font-size: 10px;">Zoom-Out</button>
<!-- <iframe src="assets/img/<?php echo $pdf; ?>" width="100%" height="350px"></iframe> -->
<!-- <iframe src="assets/img/AnupChavhan_Resume.pdf" width="100%" height="300px"></iframe> -->
<img src="assets/img/<?php echo $pdf; ?>" id="pic" class="card-img-bottom" alt="..." style="height:auto;">
</div>
</div>
</div>
<!-- End Sales Card -->
<!-- Customers Card -->
<div class="col-sm-4">
<div class="card info-card customers-card hide">
<div class="card-body" style="height: 550px; max-height: 82vh;overflow-y: scroll;">
<div class="card-title">
<h4 style="font-family: Times New Roman;font-size: 19px;">
<b>
<center>New Form</center>
</b>
</h4>
<p>Health Insurance</p>
</div>
<form method="post" >
<div class="row mb-3">
<div class="form-group" >
<input name="image_no" type="text" class="form-control" placeholder="Image No">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="fname" type="text" class="form-control" placeholder="fname">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="lname" type="text" class="form-control" placeholder="lname">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="email" type="text" class="form-control" placeholder="email">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="contact" type="text" class="form-control" placeholder="contact">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="address" type="text" class="form-control" placeholder="address">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="city" type="text" class="form-control" placeholder="city">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="state" type="text" class="form-control" placeholder="state">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="zipcode" type="text" class="form-control" placeholder="zipcode">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="bloodgroup" type="text" class="form-control" placeholder="bloodgroup">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="height" type="text" class="form-control" placeholder="height">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="weight" type="text" class="form-control" placeholder="weight">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="age" type="text" class="form-control" placeholder="age">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="marital_status" type="text" class="form-control" placeholder="marital_status">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="ip" type="text" class="form-control" placeholder="IP">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="policy_no" type="text" class="form-control" placeholder="policy_no">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="dob" type="text" class="form-control" placeholder="dob">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="emg_contact" type="text" class="form-control" placeholder="emg_contact">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="dr_id" type="text" class="form-control" placeholder="dr_id">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="dr_fname" type="text" class="form-control" placeholder="dr_fname">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="dr_lname" type="text" class="form-control" placeholder="dr_lname">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="nurse_name" type="text" class="form-control" placeholder="nurse_name">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="hospital_reg_no" type="text" class="form-control" placeholder="hospital_reg_no">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="hospital_add" type="text" class="form-control" placeholder="hospital_add">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="hospital_contact_no" type="text" class="form-control" placeholder="hospital_contact_no">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="hospital_email" type="text" class="form-control" placeholder="hospital_email">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="agent_fname" type="text" class="form-control" placeholder="agent_fname">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="agent_lname" type="text" class="form-control" placeholder="agent_lname">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="agent_contact_no" type="text" class="form-control" placeholder="agent_contact_no">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="agent_email" type="text" class="form-control" placeholder="agent_email">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="agent_address" type="text" class="form-control" placeholder="agent_address">
</div>
</div>
<div class="row mb-3">
<div class="form-group">
<input name="agent_code" type="text" class="form-control" placeholder="agent_code">
</div>
</div>
<div class="text-center">
<button type="submit" name="submit" class="btn btn-primary" style="background-image:linear-gradient( rgba(252,37,103,1) 0%, rgba(250,38,151,1) );">Submit</button>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
<!-- End Left side columns -->
</div>
</section>
</main>
<!-- End #main -->
<script>
function zoomIn() {
var pic = document.getElementById("pic");
var width = pic.clientWidth;
pic.style.width = width + 100 + "px";
}
function zoomOut() {
var pic = document.getElementById("pic");
var width = pic.clientWidth;
pic.style.width = width - 100 + "px";
}
</script>
<?php
include "footer.php";
?>