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acceptor.html
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acceptor.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Recipient Data Form</title>
<link rel="stylesheet" href="../static/acceptor-style.css">
<link rel="preconnect" href="https://fonts.googleapis.com">
<link rel="preconnect" href="https://fonts.gstatic.com" crossorigin>
<link href="https://fonts.googleapis.com/css2?family=Montserrat:ital,wght@0,100..900;1,100..900&display=swap" rel="stylesheet">
</head>
<body>
<div class="container">
<h1>Recipient Data Form</h1>
<form id="recipientForm" class="form-grid" method="post">
<!-- Personal Identification -->
<fieldset>
<legend>Personal Identification</legend>
<label for="recipientName">Full Name:</label>
<input type="text" id="recipientName" name="recipientName" required>
<label for="recipientDob">Date of Birth:</label>
<input type="date" id="recipientDob" name="recipientDob" required>
<label for="recipientContact">Contact Information:</label>
<input type="tel" id="recipientPhone" name="recipientPhone" placeholder="Phone" required>
<input type="email" id="recipientEmail" name="recipientEmail" placeholder="Email" required>
<label for="recipientAddress">Address:</label>
<textarea id="recipientAddress" name="recipientAddress" rows="3" required></textarea>
</fieldset>
<!-- Medical Information -->
<fieldset>
<legend>Medical Information</legend>
<label for="recipientDiagnosis">Diagnosis and Treatment Details:</label>
<textarea id="recipientDiagnosis" name="recipientDiagnosis" rows="3" required></textarea>
<label for="recipientBloodType">Blood Type and Rh Factor:</label>
<select id="recipientBloodType" name="recipientBloodType" required>
<option value="A+">A+</option>
<option value="A-">A-</option>
<option value="B+">B+</option>
<option value="B-">B-</option>
<option value="AB+">AB+</option>
<option value="AB-">AB-</option>
<option value="O+">O+</option>
<option value="O-">O-</option>
</select>
<label for="recipientMedications">Current Medications:</label>
<textarea id="recipientMedications" name="recipientMedications" rows="3"></textarea>
<label for="recipientAllergies">Allergies:</label>
<textarea id="recipientAllergies" name="recipientAllergies" rows="3"></textarea>
<label for="recipientTransfusions">Previous Transfusion History:</label>
<textarea id="recipientTransfusions" name="recipientTransfusions" rows="3"></textarea>
</fieldset>
<!-- Health Status -->
<fieldset>
<legend>Health Status</legend>
<label for="recipientVitalSigns">Vital Signs (e.g., blood pressure, temperature):</label>
<textarea id="recipientVitalSigns" name="recipientVitalSigns" rows="3"></textarea>
<label for="recipientLabTests">Lab Test Results (e.g., hemoglobin levels, cross-matching results):</label>
<textarea id="recipientLabTests" name="recipientLabTests" rows="3"></textarea>
</fieldset>
<!-- Consent -->
<fieldset>
<legend>Consent</legend>
<label>
<input type="checkbox" name="recipientConsentReceive" required> I agree to receive blood
</label>
<label>
<input type="checkbox" name="recipientConsentMedical" required> I consent to any related medical procedures or testing
</label>
</fieldset>
<!-- Emergency Contact Information -->
<fieldset>
<legend>Emergency Contact Information</legend>
<label for="recipientEmergencyContact">Emergency Contact Name:</label>
<input type="text" id="recipientEmergencyContact" name="recipientEmergencyContact" required>
<label for="recipientEmergencyPhone">Emergency Contact Phone:</label>
<input type="tel" id="recipientEmergencyPhone" name="recipientEmergencyPhone" required>
</fieldset>
<!-- Insurance Information -->
<fieldset>
<legend>Insurance Information (if applicable)</legend>
<label for="recipientInsurance">Insurance Details:</label>
<textarea id="recipientInsurance" name="recipientInsurance" rows="3"></textarea>
</fieldset>
<button type="submit">Submit Recipient Data</button>
</form>
</div>
</body>
</html>