<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css">
<script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/js/bootstrap.min.js"></script>
<script src="//code.jquery.com/jquery-1.11.1.min.js"></script>
<!------ Include the above in your HEAD tag ---------->
<div class="container" id="wrap">
<div class="row">
<div class="col-md-6 col-md-offset-3">
<form action="r" method="post" accept-charset="utf-8" class="form" role="form">
<legend>Patient/Client Information</legend>
<input type="text" name="firstname" value="" class="form-control input-lg" placeholder="First Name" />
<div class="row">
<div class="col-xs-4 ">
<input type="text" class="form-control input-lg" placeholder="Middle Name">
</div>
</div>
<input type="text" name="midlename" value="" class="form-control input-lg" placeholder="Middle Name" />
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Last Name" />
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Date Of Birth (mm/dd/yyyy)"/>
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="Street"/>
<input type="text" name="lastname" value="" class="form-control input-lg" placeholder="City"/>
<input type="text" name="email" value="" class="form-control input-lg" placeholder="Your Email" />
<input type="password" name="password" value="" class="form-control input-lg" placeholder="Password" /><input type="password" name="confirm_password" value="" class="form-control input-lg" placeholder="Confirm Password" /> <label>Birth Date</label> <div class="row">
<div class="col-xs-4 col-md-4">
<select name="month" class = "form-control input-lg">
<option value="01">Jan</option>
<option value="02">Feb</option>
<option value="03">Mar</option>
<option value="04">Apr</option>
<option value="31">31</option>
</select> </div>
<div class="col-xs-4 col-md-4">
<select name="year" class = "form-control input-lg">
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
</select> </div>
</div>
<label>Gender : </label> <label class="radio-inline">
<input type="radio" name="gender" value="M" id=male /> Male
</label>
<label class="radio-inline">
<input type="radio" name="gender" value="F" id=female /> Female
</label>
<br />
<span class="help-block">By clicking Create my account, you agree to our Terms and that you have read our Data Use Policy, including our Cookie Use.</span>
<button class="btn btn-lg btn-primary btn-block signup-btn" type="submit">
Create my account</button>
</form>
</div>
</div>
</div>
</div>
#wrap{
background-image: -ms-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* Mozilla Firefox */
background-image: -moz-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* Opera */
background-image: -o-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* Webkit (Safari/Chrome 10) */
background-image: -webkit-gradient(linear, left top, left bottom, color-stop(0, #FFFFFF), color-stop(1, #D3D8E8));
/* Webkit (Chrome 11+) */
background-image: -webkit-linear-gradient(top, #FFFFFF 0%, #D3D8E8 100%);
/* W3C Markup, IE10 Release Preview */
background-image: linear-gradient(to bottom, #FFFFFF 0%, #D3D8E8 100%);
background-repeat: no-repeat;
background-attachment: fixed;
}
legend{
color:#141823;
font-size:25px;
font-weight:bold;
}
.signup-btn {
background: #79bc64;
background-image: -webkit-linear-gradient(top, #79bc64, #578843);
background-image: -moz-linear-gradient(top, #79bc64, #578843);
background-image: -ms-linear-gradient(top, #79bc64, #578843);
background-image: -o-linear-gradient(top, #79bc64, #578843);
background-image: linear-gradient(to bottom, #79bc64, #578843);
-webkit-border-radius: 4;
-moz-border-radius: 4;
border-radius: 4px;
text-shadow: 0px 1px 0px #898a88;
-webkit-box-shadow: 0px 0px 0px #a4e388;
-moz-box-shadow: 0px 0px 0px #a4e388;
box-shadow: 0px 0px 0px #a4e388;
font-family: Arial;
color: #ffffff;
font-size: 20px;
padding: 10px 20px 10px 20px;
border: solid #3b6e22 1px;
text-decoration: none;
}
.signup-btn:hover {
background: #79bc64;
background-image: -webkit-linear-gradient(top, #79bc64, #5e7056);
background-image: -moz-linear-gradient(top, #79bc64, #5e7056);
background-image: -ms-linear-gradient(top, #79bc64, #5e7056);
background-image: -o-linear-gradient(top, #79bc64, #5e7056);
background-image: linear-gradient(to bottom, #79bc64, #5e7056);
text-decoration: none;
}
.navbar-default .navbar-brand{
color:#fff;
font-size:30px;
font-weight:bold;
}
.form .form-control { margin-bottom: 10px; }
@media (min-width:768px) {
#home{
margin-top:50px;
}
#home .slogan{
color: #0e385f;
line-height: 29px;
font-weight:bold;
}
}
