123 lines
4.2 KiB
HTML
123 lines
4.2 KiB
HTML
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<!DOCTYPE html>
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<html>
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<head>
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<title>Contact</title>
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<meta charset="utf-8"/>
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<link href="images/logo.png" rel="icon" type="image/x-icon">
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<link href="css/style.css.css" rel="stylesheet" media="all" type="text/css">
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<link href="css/formulaire.css.css" rel="stylesheet" media="all" typr="text/css">
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</head>
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<body class="bodyform">
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<header>
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<span class="banière"><img src="images/medicale-banniere.jpg" width="99%" height="90px"/></span>
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</header>
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<br>
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<br>
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<nav>
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<table class="nav">
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<tr>
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<td>
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<form action="index.html.html" method="get" enctype="text/plain">
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<button class="bouton" type="submit">Accueil</button>
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</form>
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</td>
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<td>
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<form action="horaires.html.html" method="get" enctype="text/plain">
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<button class="bouton" type="submit">Horaires</button>
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</form>
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</td>
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<td>
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<form action="specialites.html.html" method="get" enctype="text/plain">
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<button class="bouton" type="submit">Spécialités</button>
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</form>
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</td>
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<td>
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<form action="priserdv.html.html" method="get" enctype="text/plain">
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<button class="bouton" type="submit">Rendez-vous</button>
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</form>
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</td>
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<td>
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<form action="formulaire.html.html" method="get" enctype="text/plain">
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<button class="bouton" type="submit">Contact</button>
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</form>
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</td>
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</tr>
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</table>
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</nav>
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<br>
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<form action="https://prendre-mon-rdv.com" method="get" enctype="text/plain" class="formule">
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<fieldset class="coordonnées">
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<table class="coordonnées2">
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<tr>
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<td><label for="nom">Nom:</label></td>
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<td class="casedroite"><input id="nom" type="text" name="nom" placeholder="votre nom" class="input1" required/></td>
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</tr>
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<tr>
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<td><label for="nom">Prénom:</label></td>
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<td class="casedroite"><input id="nom" type="text" name="prénom" placeholder="votre prénom" class="input1" required/></td>
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</tr>
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<tr>
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<td><label for="nom">Date de naissance:</label></td>
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<td id="date"><input id="date" type="Date" name="date" class="input3" required/></td>
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</tr>
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<tr>
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<td><label for="nom">Mail:</label></td>
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<td class="casedroite"><input id="mail" type="email" name="mail" placeholder="votre mail" class="input4" required/></td>
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</tr>
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<tr>
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<td><label for="nom">Votre site:</label></td>
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<td class="casedroite"><input id="site" type="url" name="site" value="http://www." class="input2"/></td>
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</tr>
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<tr>
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<td><label for="nom">Genre:</label>
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<td class="casedroite"><input type="radio" name="xx" value="xy"/>Homme
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<input type="radio" name="xx" value="xx"/>Femme
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</tr>
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<tr>
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<td>
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<label for="nom">Pays:</label>
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<td class="casedroite">
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Votre pays:
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<select name="select">
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<optgroup label="Europe">
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<option value="France">France</option>
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<option value="Belgique">Belgique</option>
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</optgroup>
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<optgroup label="Asie">
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<option value="Chine">Chine</option>
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<option value="Russie">Russie</option>
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</optgroup>
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<optgroup label="Amériques">
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<option value="Etats-Unis">Etats-Unis</option>
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<option value="Brésil">Brésil</option>
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</optgroup>
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</td>
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</select>
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</td>
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</tr>
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</table>
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</fieldset>
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<fieldset>
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<b>Schéma vaccinal</b>
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<br>
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<input name="xx[]" type="checkbox" value="v1" />Covid - Schéma complet<br>
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<input name="xx[]" type="checkbox" value="v2" />Autres vaccins<br>
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<br>
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<textarea maxlength="500" rows="5" cols="52">
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Vos antécédents médicaux
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</textarea>
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</fieldset>
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<fieldset>
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<input type="file" name="photo"/><br><br>
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<input type="submit" value="Envoyer"/>
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<input type="reset" value="Effacer"/>
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</fieldset>
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</form>
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<br>
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<br>
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<footer>
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En cas d'abscence, vous pouvez <a href="https://www.doctolib.fr">consulter ce site</a><br>
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Je suis par ailleurs membre de démonstration des MMT.
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</footer>
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</body>
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</html>
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