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<!DOCTYPE html>
<html lang="en">
<head>
<title>Login</title>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<link href="https://fonts.googleapis.com/css?family=Nunito+Sans:200,300,400,600,700,800,900&display=swap" rel="stylesheet">
<link rel="stylesheet" href="css/open-iconic-bootstrap.min.css">
<link rel="stylesheet" href="css/animate.css">
<link rel="stylesheet" href="css/owl.carousel.min.css">
<link rel="stylesheet" href="css/owl.theme.default.min.css">
<link rel="stylesheet" href="css/magnific-popup.css">
<link rel="stylesheet" href="css/aos.css">
<link rel="stylesheet" href="css/ionicons.min.css">
<link rel="stylesheet" href="css/bootstrap-datepicker.css">
<link rel="stylesheet" href="css/jquery.timepicker.css">
<link rel="stylesheet" href="css/flaticon.css">
<link rel="stylesheet" href="css/icomoon.css">
<link rel="stylesheet" href="css/style.css">
<link rel="stylesheet" href="https://ajax.googleapis.com/ajax/libs/jqueryui/1.12.1/themes/flick/jquery-ui.css">
<script src="https://ajax.googleapis.com/ajax/libs/jqueryui/1.12.1/jquery-ui.min.js"></script>
</head>
<body>
<nav class="navbar navbar-expand-lg navbar-dark ftco_navbar bg-dark ftco-navbar-light" id="ftco-navbar">
<div class="digitallogo">
<img src="2.png" alt="Digital India Logo" width="150px">
</div>
<a class="navbar-brand" href="index.html">NBSU</a>
<button class="navbar-toggler" type="button" data-toggle="collapse" data-target="#ftco-nav" aria-controls="ftco-nav" aria-expanded="false" aria-label="Toggle navigation">
<span class="oi oi-menu"></span> Menu
</button>
<div class="collapse navbar-collapse" id="ftco-nav">
<ul class="navbar-nav ml-auto">
<li class="nav-item"><a href="index.html" class="nav-link">Home</a></li>
<li class="nav-item active"><a href="about.html" class="nav-link">About</a></li>
<li class="nav-item"><a href="speakers.html" class="nav-link">Guide</a></li>
<li class="nav-item"><a href="schedule.html" class="nav-link">FAQ</a></li>
<li class="nav-item"><a href="blog.html" class="nav-link">Report</a></li>
<li class="nav-item"><a href="contact.html" class="nav-link">Contact Us</a></li>
<li class="nav-item cta mr-md-2"><a href="login.html" class="nav-link">Login</a></li>
</ul>
</div>
</div>
</nav>
<!-- END nav -->
<section class="hero-wrap hero-wrap-2 js-fullheight" style="background-image: url('images/bg_2.jpg');" data-stellar-background-ratio="0.5">
<div class="overlay"></div>
<div class="container">
<div class="row no-gutters slider-text js-fullheight align-items-end justify-content-start">
<div class="col-md-9 ftco-animate pb-5">
</div>
</div>
</div>
</section>
<section class="ftco-section">
<div class="container">
<div class="row d-flex ">
<div class="col-md-4 d-flex ftco-animate">
<div id="inp" >
<form action="/submit" method="POST" style="color: black" style="font-weight: bold" >
Birth Certificate Number :
<input type="number" name="birth_certificate_number" id="birth_certificate_number">
<br>
Age(in days) :
<input type="number" id="age" name="age" >
<br>
District:
<select name="district" id="district">
<option value="District">District</option>
<option value="Amritsar">Amritsar</option>
<option value="Ludhiana">Ludhiana</option>
<option value="Moga">Moga</option>
<option value="Patiala">Patiala</option>
</select>
<br>
Hospital:
<select name="hospital" id="hospital">
<option value="Hospital">Hospital</option>
<option value="DMC">DMC</option>
<option value="CMC">CMC</option>
<option value="Apollo">Apollo</option>
<option value="Fortis">Fortis</option>
</select>
<br>
Weight:
<input type="number" name="weight" id="weight">
<br>
Diagnosis:
<input type="text" name="diagnosis" id="diagnosis">
<br>
Outcome:
<select name="outcome" id="outcome">
<option value="=Outcome">Outcome</option>
<option value="Recommended">Recommended</option>
<option value="Referred">Referred</option>
<option value="LAMA">LAMA</option>
<option value="Death">Death</option>
</select>
<br>
Comments:
<input type="text" name="comments" id="comments">
<br>
<button type="submit" id="submit" class="ui-button ui-corner-all ui-widget">Submit</button>
</fieldset>
</form>
</div>
</div>
</div>
</section>
</section>
</section> <!-- .section -->
<footer class="ftco-footer ftco-bg-dark ftco-section">
<div class="container">
<div class="row mb-5">
<div class="col-md">
<div class="ftco-footer-widget mb-4">
<h2 class="ftco-heading-2">NBSU</h2>
<ul class="ftco-footer-social list-unstyled float-md-left float-lft mt-5">
<li class="ftco-animate"><a href="#"><span class="icon-twitter"></span></a></li>
<li class="ftco-animate"><a href="#"><span class="icon-facebook"></span></a></li>
<li class="ftco-animate"><a href="#"><span class="icon-instagram"></span></a></li>
</ul>
</div>
</div>
<div class="col-md">
<div class="ftco-footer-widget mb-4 ml-md-5">
<h2 class="ftco-heading-2">Useful Links</h2>
<ul class="list-unstyled">
<li><a href="#" class="py-2 d-block">Guide</a></li>
<li><a href="#" class="py-2 d-block">FAQ</a></li>
</ul>
</div>
</div>
<div class="col-md">
<div class="ftco-footer-widget mb-4">
<h2 class="ftco-heading-2">Privacy</h2>
<ul class="list-unstyled">
<li><a href="#" class="py-2 d-block">About </a></li>
<li><a href="#" class="py-2 d-block">Contact Us</a></li>
<li><a href="#" class="py-2 d-block">Report</a></li>
</ul>
</div>
</div>
<div class="col-md">
<div class="ftco-footer-widget mb-4">
<h2 class="ftco-heading-2">Queries?</h2>
<div class="block-23 mb-3">
<ul>
<li><span class="icon icon-map-marker"></span><span class="text">Main Secretariat,<br> Chandigarh, India</span></li>
<li><a href="#"><span class="icon icon-phone"></span><span class="text">+91 9815092059</span></a></li>
<li><a href="#"><span class="icon icon-envelope"></span><span class="text">abc@gmail.com</span></a></li>
</ul>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12 text-center">
<p>
Copyright ©<script>document.write(new Date().getFullYear());</script> All rights reserved @techgeeks </a>
</p>
</div>
</div>
</div>
</footer>
<!-- loader -->
<div id="ftco-loader" class="show fullscreen"><svg class="circular" width="48px" height="48px"><circle class="path-bg" cx="24" cy="24" r="22" fill="none" stroke-width="4" stroke="#eeeeee"/><circle class="path" cx="24" cy="24" r="22" fill="none" stroke-width="4" stroke-miterlimit="10" stroke="#F96D00"/></svg></div>
<script src="js/jquery.min.js"></script>
<script src="js/jquery-migrate-3.0.1.min.js"></script>
<script src="js/popper.min.js"></script>
<script src="js/bootstrap.min.js"></script>
<script src="js/jquery.easing.1.3.js"></script>
<script src="js/jquery.waypoints.min.js"></script>
<script src="js/jquery.stellar.min.js"></script>
<script src="js/owl.carousel.min.js"></script>
<script src="js/jquery.magnific-popup.min.js"></script>
<script src="js/aos.js"></script>
<script src="js/jquery.animateNumber.min.js"></script>
<script src="js/scrollax.min.js"></script>
<script src="https://maps.googleapis.com/maps/api/js?key=AIzaSyBVWaKrjvy3MaE7SQ74_uJiULgl1JY0H2s&sensor=false"></script>
<script src="js/google-map.js"></script>
<script src="js/main.js"></script>
</body>
</html>