97 lines
5.6 KiB
PHP
97 lines
5.6 KiB
PHP
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<!-- begin app -->
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<div class="app">
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<!-- begin app-wrap -->
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<div class="app-wrap">
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<!-- begin pre-loader -->
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<div class="loader">
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<div class="h-100 d-flex justify-content-center">
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<div class="align-self-center">
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<img src="assets/img/loader/loader.svg" alt="loader">
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</div>
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</div>
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</div>
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<!-- end pre-loader -->
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<!--start login contant-->
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<div class="app-contant">
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<div class="bg-white">
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<div class="container-fluid p-0">
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<div class="row no-gutters">
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<div class="col-sm-6 col-lg-5 col-xxl-3 align-self-center order-2 order-sm-1">
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<div class="d-flex align-items-center h-100-vh">
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<div class="register p-5">
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<h1 class="mb-2">Merms Providers</h1>
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<p>Welcome, Please create your account.</p>
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<form action="/register" method='POST' class="mt-2 mt-sm-5">
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<div class="row">
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<div class="col-12">
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<div class="form-group">
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<label class="control-label">Practice Name*</label>
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<input type="text" class="form-control" placeholder="Practice name" />
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</div>
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</div>
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<div class="col-12 col-sm-6">
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<div class="form-group">
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<label class="control-label">First Name*</label>
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<input type="text" class="form-control" placeholder="First Name" />
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</div>
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</div>
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<div class="col-12 col-sm-6">
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<div class="form-group">
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<label class="control-label">Last Name*</label>
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<input type="text" class="form-control" placeholder="Last Name" />
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</div>
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</div>
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<div class="col-12">
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<div class="form-group">
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<label class="control-label">Email*</label>
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<input type="email" class="form-control" placeholder="Email" />
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</div>
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</div>
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<div class="col-12">
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<div class="form-group">
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<label class="control-label">Username*</label>
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<input type="text" class="form-control" placeholder="Username" />
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</div>
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</div>
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<div class="col-12">
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<div class="form-group">
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<label class="control-label">Password*</label>
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<input type="password" class="form-control" placeholder="Password" />
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</div>
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</div>
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<div class="col-12">
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<div class="form-check">
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<input class="form-check-input" type="checkbox" id="gridCheck">
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<label class="form-check-label" for="gridCheck">
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I accept terms & policy
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</label>
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</div>
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</div>
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<div class="col-12 mt-3">
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<button type="submit" class="btn btn-primary">Sign up</button>
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</div>
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<div class="col-12 mt-3">
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<p>Already have an account ?<a href="/login"> Sign In</a></p>
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</div>
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</div>
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</form>
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</div>
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</div>
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</div>
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<div class="col-sm-6 col-xxl-9 col-lg-7 o-hidden order-1 order-sm-2" style="background-color:red; background-image: url('assets/img/bg/provider.jpg'); background-size: 100% 100%;">
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<!-- img class="img-fluid" src="assets/img/bg/provider.jpg" alt="" style="background-size:contain;" -->
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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<!-- end app-wrap -->
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</div>
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<!-- end app -->
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