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    Putri Luis

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    Putri Luis

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    Putri Luis

    Uploaded by

    Putri Luis
    2 views3 pages

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    putri luis

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    Copyright:

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    2 views3 pages

    Putri Luis

    Uploaded by

    Putri Luis

    Copyright:

    © All Rights Reserved
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    of 3

    Nama : Putri Luis Santi

    NPM : 22111100023
    Kelas : Informatika 22A2

    <!DOCTYPE html>
    <html>
    <head>
    <title>form pendaftaran pasien</title>
    </head>
    <body>
    <form action="contact.php" method="POST">
    <fieldset>
    <legend>form pendaftaran</legend>
    <p>
    <table class="table-form" nama="10" width="100%" cellpadding="0"
    cellspacing="0">
    <label>Nama:</label>
    <input type="text" name="nama" placeholder="PUTRI LUIS SANTI..." />
    <tr>

    </p>
    <p>
    <label>Nomor Identitas:</label>
    <input type="text" name="Nomor" placeholder="09..." />
    </p>
    <p>
    <label>Nomor HP:</label>
    <input type="text" name="Nomor" placeholder="089601124639..." />
    </p>
    <p>
    <label>Password:</label>
    <input type="password" name="password" placeholder="090903..." />
    </p>
    <p>
    <label>Kelas:</label
    <label><input type="radio" name="kelas" value="kelas" /> 22A1</label>
    <label><input type="radio" name="Kelas" value="kelas" /> 22A2</label>
    <label><input type="radio" name="kelas" value="kelas" /> 22A</label>
    <label><input type="radio" name="kelas" value="kelas" /> 22B</label>
    </p>
    <p>
    <label>Tanggal Masuk:</label>
    <select name="5" class="form">
    <option>1</option>
    <option>2</option>
    <option>3</option>
    <option>4</option>
    <option>5</option>
    <option>6</option>
    <option>7</option>
    <option>8</option>
    <option>9</option>
    <option>10</option>
    </select>
    <select name="bln_masuk" class="form">
    <option>januari</option>
    <option>februari</option>
    <option>maret</option>
    <option>april</option>
    <option>mei</option>
    <option>juni</option>
    <option>juli</option>
    <option>agustus</option>
    <option>september</option>
    <option>oktober</option>
    <option>november</option>
    <option>desember</option>
    </select>
    <select name="thn_masuk" class="form">
    <option>2023</option>
    <option>2024</option>
    <option>2025</option>
    <option>2026</option>
    <option>2027</option>
    <option>2028</option>
    </select>
    </p>
    <p>
    <label>Jumlah Penyakit:</label>
    <select name="jumlah-penyakit" value="form">
    <option>16</option>
    <option>27</option>
    <option>35</option>
    </select>
    </p>
    <p>
    <input type="submit" name="submit" value="Kirim data" />
    <input type="submit" name="submit" value="Hitung" />
    </p>
    </fieldset>
    </form>
    </body>
    </html>
    HASIL :

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