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creditcard.php
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creditcard.php
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<!DOCTYPE html>
<?php include "config.php"?>
<html>
<head>
<link rel="stylesheet" type="text/css" href="bootstrap.min.css">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css">
</head>
<style>
input[type=text], select {
width: 100%;
padding: 12px 20px;
margin: 8px 0;
display: inline-block;
border: 1px solid #ccc;
border-radius: 4px;
box-sizing: border-box;
}
input[type=number], select {
width: 100%;
padding: 12px 20px;
margin: 8px 0;
display: inline-block;
border: 1px solid #ccc;
border-radius: 4px;
box-sizing: border-box;
}
input[type=date], select {
width: 100%;
padding: 12px 20px;
margin: 8px 0;
display: inline-block;
border: 1px solid #ccc;
border-radius: 4px;
box-sizing: border-box;
}
input[type=submit] {
width: 100%;
background-color: #008080;
color: white;
padding: 14px 20px;
margin: 8px 0;
border: none;
border-radius: 4px;
cursor: pointer;
}
input[type=submit]:hover {
background-color: #6195CA;
}
div {
border-radius: 5px;
background-color: #f2f2f2;
padding: 30px;
}
</style>
<body>
<div style="padding-top: 20px;" class="container">
<div style="padding-left: 490px;">
<h3>Pay Invoice</h3>
<i class="fa fa-cc-mastercard" style="font-size:36px"></i><i class="fa fa-cc-paypal" style="font-size:36px"></i><i class="fa fa-cc-visa" style="font-size:36px"></i>
</div>
<form method="POST" action="takepayment.php" >
<!-- <i class="fa fa-cc-mastercard" style="font-size:36px"></i><i class="fa fa-cc-paypal" style="font-size:36px"></i> -->
<br>
<label for="username">User name</label>
<input type="text" id="username" name="username" pattern="[A-Za-z0-9_]{1,40}" title="You can use (a-z) / (A-Z) / (0-9) / _ and less than 40 character" required>
<br><br>
<label for="presid">Prescription Id</label>
<input type="number" id="presid" name="presid" pattern="[0-9]" title="You can use (0-9)" required>
<br><br>
<label for="today"><b>Date</b></label>
<input type="date" id="today" name="today" required min="05-26-2018">
<br><br>
<label for="amount">Payment Amount</label>
<input type="Number" id="amount" name="amount" required >
<br><br>
<label for="nameoncard">Name on card</label>
<input type="text" id="nameoncard" name="nameoncard" pattern="[A-Za-z]{1,40}" title="You can use (a-z) / (A-Z) / _ and less than 40 character" required>
<br><br>
<label for="cardnumber">Card Number</label>
<input type="Number" id="cardnumber" name="cardnumber" required >
<br><br>
<label for="securitynum">Security Number</label>
<input type="Number" id="securitynum" name="securitynum" required >
<br><br>
<label for="exp">Expiry Date</label>
<input type="Date" id="exp" name="exp" required >
<br><br>
<input type="submit" name="submit">
</form>
</div>
</body>
</html>