<style>
input::-webkit-outer-spin-button,
input::-webkit-inner-spin-button {
  -webkit-appearance: none;
  margin: 0;
}


</style>


  <hr>
  <hr>
  <hr>
  <hr>
 
    <section class="breadcrumb_part breadcrumb_bg">
        <div class="container">
            <div class="row">
                <div class="col-lg-12">
                    <div class="breadcrumb_iner">
                        <div class="breadcrumb_iner_item">
                            <h2>Daftar </h2>
                            <h2>Pasien</h2>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </section>
    <!-- breadcrumb start-->

         
    <div class="container">
        <div class="card" >
            <div class="card-header">
                    <h2> Silahkan Isi Data Diri Pasien</h2>
                    </div>
                <div class="card-body">
        
                <form id="myForm" class="form-row">
                    <input type="hidden" id="iInput"  class="form-control" /></input>
                    <!-- <input type="text" id="Provinsi"  class="form-control" /></input> -->

                    <div class="form-group col-md-4">
                        <label><h5>No Induk Kependudukan (NIK)</h5></label>
                        <input type="number" id="ktp" class="form-control" placeholder="No Induk Kependudukan (NIK)" max="9999999999999999" maxlength="16"></input>
                    </div>

                    <div class="form-group col-md-4">
                        <label><h5>Nama Pasien</h5></label>
                        <input type="text" id="nama"  class="form-control"   placeholder="Nama Lengkap" ></input>
                    </div>
                    <div class="form-group col-md-4">
                        <label><h5>Tanggal Lahir</h5></label>
                        <input type="date" id="tanggal_lahir"  class="form-control" /></input>
                    </div>
                    <div class="form-group col-md-4">
                         <label><h5>Jenis Kelamin</h5></label><br>
                        <input type="radio" id="laki_laki" name="gender" value="L">
                        <label for="male"><h5>Laki-Laki</h5></label>
                        <input type="radio" id="perempuan" name="gender" value="P">
                        <label for="female"><h5>Perempuan</h5></label>
                    </div>

                    <div class="form-group col-md-4" >
                        <label><h5>Tempat Lahir</h5></label>
                        <input  type="text" id="tempat_lahir" rows="3" class="form-control" placeholder="Alamat"/></textarea >
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5>Agama</h5></label>
                        <select name="agama" id="agama"  class="form-control">
                        <option disabled selected>Agama </option>
                        </select> 
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5>Pekerjaan</h5></label>
                        <select name="pekerjaan" id="pekerjaan"  class="form-control">
                        <option disabled selected>Pekerjaan </option>
                        </select> 
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5>Pendidikan</h5></label>
                        <select name="Pendidikan" id="Pendidikan"  class="form-control">
                        <option disabled selected>Pendidikan </option>
                        </select> 
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5>Status Perkawinan</h5></label>
                        <select name="status_perkawinan" id="status_perkawinan"  class="form-control">
                        <option disabled selected>Status Perkawinan </option>
                        </select> 
                    </div>
                   
                    <div class="form-group col-md-4" >
                        <label><h5>Alamat</h5></label>
                        <input  type="text" id="alamat" rows="3" class="form-control" placeholder="Alamat"/></textarea >
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5>Provinsi</h5></label>
                        <select name="Provinsi" id="Provinsi"  class="form-control">
                        <option disabled selected>Provinsi </option>
                        </select> 
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5></h5>Kota/Kabupaten</label>
                        <select name="Kota" id="Kota"  class="form-control">
                        <option disabled selected> </option>
                        </select> 
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5></h5>Kecamatan</label>
                        <select name="kecamatan" id="kecamatan"  class="form-control">
                        <option disabled selected> </option>
                        </select> 
                    </div>
                    <div class="form-group col-md-4">
                        <label> <h5></h5>Kelurahan</label>
                        <select name="Kelurahan" id="Kelurahan"  class="form-control">
                        <option disabled selected> </option>
                        </select> 
                    </div>

                    <div class="form-group col-md-4">
                        <label><h5>No HP</h5></label>
                        <input type="number" id="no_hp"  class="form-control " placeholder="No Handphone" maxlength="13" /></input>
                    </div>
                   
                    

                    
                </form>
            </div>
                <div class="card-footer" >
                     <p class="card-text"></p>
                        <button type="button"  class="btn btn-primary" id="tambahdata" style="float: right;"> Daftar Pasien</button>
                </div>    
        
        </div>
    </div> 
    <br>









