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