Location: PHPKode > projects > TherapyDoc > therapydoc_1.3.1_3/view/physician/input_form.php
<?
session_start();
if(!isset($_SESSION['myusername'])){
	header("location:../index.php");
}
$a=$_SESSION['data_entry'];
if($a==1) {
}
elseif($a==0) {
	header("location:http://$sname/therapydoc/noauth.php");
}
include 'globals.inc';
require_once "connect.inc";
include '../../classes/therapydoc/select_lists.php';
if(isset($_GET['l'])){$l=$_GET['l'];}
else{$l="";}
if(isset($_GET['f'])){$f=$_GET['f'];}
else{$f="";}
if(isset($_GET['d'])){$d=$_GET['d'];}
else{$d="";}
?>

<html>
<head>
<link href="../../CSS/main.css" rel="stylesheet" type="text/css">
<script language="JavaScript"
	src="../../classes/therapydoc/validation/physician_form.js"></script>
<script type="text/javascript" src="../../classes/therapydoc/menu.js"></script>
</head>
<body id="main_body">
<div id="wrapper"><?php include '../../classes/therapydoc/menu.php';?>
<h1>Enter New Physician Information</h1>
<form method="post" name="physician_form"
	action="../../classes/therapydoc/physician/insert_physician.php?l=<?php echo $l; ?>&&f=<?php echo $f; ?>&&d=<?php echo $d; ?>"
	onClick="return checkForm();">

<table class="forms">

	<tr>
		<td><label for="lname">Last Name</label></td>
		<td><input id="lname" name="lname" class="txt" maxlength="255"
			size="25" value="" /></td>
		<td><label for="fname">First Name</label></td>
		<td><input id="fname" name="fname" class="txt" maxlength="255"
			size="25" value="" /></td>
	</tr>

	<tr>
		<td><label for="add1">Address 1</label></td>
		<td><input id="add1" name="add1" class="txt" maxlength="255" size="25"
			value="" /></td>
		<td><label for="add2">Address 2</label></td>
		<td><input id="add2" name="add2" class="txt" maxlength="255" size="25"
			value="" /></td>
	</tr>

	<tr>
		<td><label for="city">City</label></td>
		<td><input id="city" name="city" class="txt" maxlength="255" size="25"
			value="" /></td>
		<td><label for="state">State</label></td>
		<td><input id="state" name="state" class="txt" maxlength="3" size="3"
			value="" /></td>
	</tr>

	<tr>
		<td><label for="zip">Zip Code</label></td>
		<td><input id="zip" name="zip" class="txt" maxlength="10" size="10"
			value="" /></td>
		<td><label for="phone">Phone</label></td>
		<td><input id="phone" name="phone" class="txt" maxlength="20"
			size="25" value="" /></td>
	</tr>

	<tr>
		<td><label for="email">Email</label></td>
		<td><input id="email" name="email" class="txt" maxlength="50"
			size="25" value="" /></td>
		<td><label for="fax">Fax</label></td>
		<td><input id="fax" name="fax" class="txt" maxlength="20" size="25"
			value="" /></td>
	</tr>

	<tr>
		<td><label for="specialty">Specialty</label></td>
		<td><?php specialty_lookup($dbh); ?></td>
	</tr>

	<tr>
		<td></td>
		<td><input type="submit" value="Finished"></td>
	</tr>
</table>
</form>
<script language="JavaScript">
new validateForm(document.forms.physician_form);
</script>

</body>
</html>
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