Input_rss
<!doctype html public "-//W3C//DTD HTML 4.0 //EN">
<html>
<head>
<title>Rumah Sehat Sejahtera</title>
</head>
<body bgcolor=#BOFFBO text=#007138>
<form action="output_rss.php" method="post">
<b><blink><font face="curlz MT" size=8>"Rumah Sehat"</blink></font>
<table border=6>
<tr>
<td> No Pendaftaran :</td>
<td><input type="text" name="no"></td>
<tr>
<td> Nama Pasien :</td>
<td><input type="text" name="nm"></td></tr>
<tr>
<td>Pilih Layanan :</td>
<td><input type="radio" name="pil" value="1">1.Konsultasi<br>
<input type="radio" name="pil" value="2">2.Pijat Refleksi<br>
<input type="radio" name="pil" value="3">3.Pijat Listrik<br>
<input type="radio" name="pil" value="4">4.Bekam<br></td>
</tr>
<tr>
<td><input type=submit name=simpan value=simpan></td>
<td><input type=reset name=bersih value=Bersih>
</td></tr></table>
</form></body></html>
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