Toggle navigation
Bootsnipp
Bootstrap
For
CSS Frameworks
Bootstrap
Foundation
Semantic UI
Materialize
Pure
Bulma
References
CSS Reference
Tools
Community
Page Builder
Form Builder
Button Builder
Icon Search
Dan's Tools
Diff / Merge
Color Picker
Keyword Tool
Web Fonts
.htaccess Generator
Favicon Generator
Site Speed Test
Snippets
Featured
Tags
By Bootstrap Version
4.1.1
4.0.0
3.3.0
3.2.0
3.1.0
3.0.3
3.0.1
3.0.0
2.3.2
Register
Login
"bill pay"
Bootstrap 4.1.1 Snippet by
shreyadm
4.1.1
Preview
HTML
View Full Screen
Fork
Fork this
970
 
0 Fav
Post to Facebook
Tweet this
<link href="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/4.1.1/js/bootstrap.min.js"></script> <script src="//cdnjs.cloudflare.com/ajax/libs/jquery/3.2.1/jquery.min.js"></script> <!------ Include the above in your HEAD tag ----------> <fieldset> <!-- Form Name --> <legend>Patient receipt</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="usrname">Name</label> <div class="col-md-4"> <input id="usrname" name="usrname" type="text" placeholder="Enter name" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="d_id">Doctor ID</label> <div class="col-md-4"> <input id="d_id" name="d_id" type="text" placeholder="Enter Doctor's ID" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="r_id">Receptionist ID</label> <div class="col-md-4"> <input id="r_id" name="r_id" type="text" placeholder="Enter Receptionist's ID" class="form-control input-md"> </div> </div> <!-- Button Drop Down --> <div class="form-group"> <label class="col-md-4 control-label" for="med">Add medicines</label> <div class="col-md-4"> <div class="input-group"> <input id="med" name="med" class="form-control" placeholder="Add medicines" type="text"> <div class="input-group-btn"> <button type="button" class="btn btn-default dropdown-toggle" data-toggle="dropdown"> ADD <span class="caret"></span> </button> <ul class="dropdown-menu pull-right"> <li><a href="#">Option one</a></li> <li><a href="#">Option two</a></li> <li><a href="#">Option three</a></li> </ul> </div> </div> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="diag">Diagnosis</label> <div class="col-md-4"> <textarea class="form-control" id="diag" name="diag"></textarea> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="amt">Total amount</label> <div class="col-md-4"> <input id="amt" name="amt" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Button --> <div class="form-group"> <label class="col-md-4 control-label" for="print_bill"></label> <div class="col-md-4"> <button id="print_bill" name="print_bill" class="btn btn-primary">Print Bill</button> </div> </div> </fieldset> </form>
Related:
See More
Free Template
Paper Bootstrap Wizard
Questions / Comments:
Post
Posting Guidelines
Formatting
- Now
×
Close
Donate
BTC: 12JxYMYi6Vt3mx3hcmP3B2oyFiCSF3FhYT
ETH: 0xCD715b2E3549c54A40e6ecAaFeB82138148a6c76