Server : ApacheSystem : Linux sh00666.bluehost.com 5.14.0-687.26.1.el9_8.x86_64 #1 SMP PREEMPT_DYNAMIC Tue Jul 14 16:32:02 EDT 2026 x86_64 User : ndkhermy ( 1200) PHP Version : 8.5.12 Disable Function : NONE Directory : /home1/ndkhermy/www/website_93b53270/ |
Upload File : |
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Appointment Form</title>
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/css/bootstrap.min.css">
<script src="https://code.jquery.com/jquery-3.3.1.min.js"></script>
</head>
<body>
<div class="container mt-5">
<div id="responseMessage" class="alert" style="display: none;"></div>
<form id="appointmentForm">
<div class="row">
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="Name">Name</label>
<input type="text" name="name" class="form-control mb-3" placeholder="type your Name" required>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="Email">Email</label>
<input type="email" name="email" class="form-control mb-3" placeholder="type your Email" required>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="Phone">Phone</label>
<input type="number" name="phone" maxlength="10" class="form-control mb-3" placeholder="type your Phone" required>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="Country">Country</label>
<input type="text" name="country" class="form-control mb-3" placeholder="type your Country" required>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="State">State</label>
<input type="text" name="state" class="form-control mb-3" placeholder="type your State" required>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="City">City</label>
<input type="text" name="city" class="form-control mb-3" placeholder="type your City">
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="Zip Code">Zip Code</label>
<input type="number" name="postcode" maxlength="10" class="form-control mb-3" placeholder="type your Zip Code" required>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label" for="Address">Address</label>
<textarea name="address" class="form-control mb-3" rows="4" placeholder="type your Address" required></textarea>
</div>
</div>
<div class="col-md-12">
<button type="submit" class="btn btn-primary">Submit</button>
</div>
</div>
</form>
</div>
<script>
$(document).ready(function() {
$('#nextBtn').on('click', function(e) {
e.preventDefault();
var name = $("input[name='name']").val();
$.ajax({
type: 'POST',
url: 'appointment.php',
data: { name: name,
email: email,
phone: phone,
country: country,
state: state,
city: city,
postcode: postcode,
address: address,
name: name,
name: name,
name: name,
name: name,
name: name,
name: name,
name: name,
name: name,
},
success: function(response) {
$('#responseMessage').removeClass('alert-danger').addClass('alert-success').html(response).show();
},
error: function() {
$('#responseMessage').removeClass('alert-success').addClass('alert-danger').html('An error occurred while submitting the form. Please try again.').show();
}
});
});
});
</script>
</body>
</html>