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pay1.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, shrink-to-fit=no">
<link rel="icon" href="images/icon2.png" type="image/x-icon">
<link rel="stylesheet" href="https://maxcdn.bootstrapcdn.com/bootstrap/4.0.0/css/bootstrap.min.css" integrity="sha384-Gn5384xqQ1aoWXA+058RXPxPg6fy4IWvTNh0E263XmFcJlSAwiGgFAW/dAiS6JXm" crossorigin="anonymous">
<link href="css/payment.css" rel="stylesheet">
<title>Pay Online</title>
</head>
<body class="bg-light">
<div style="text-align: center; padding-top: 10px;">
<h1>Phoenix Hospital</h1>
<h3>Payment Gateway</h3>
</div><br><br>
<div class="container">
<div class="row">
<div class="col-md-4 order-md-2 mb-4">
<h4 class="d-flex justify-content-between align-items-center mb-3">
<span class="text-muted">Your cart</span>
<span class="badge badge-secondary badge-pill">1</span>
</h4>
<ul class="list-group mb-3">
<li class="list-group-item d-flex justify-content-between lh-condensed">
<div>
<h6 class="my-0">Accommodation</h6>
<small class="text-muted">Deluxe A/C Room</small>
</div>
<span class="text-muted">₹2000</span>
</li>
<li class="list-group-item d-flex justify-content-between">
<span>Total (INR)</span>
<strong>₹2000</strong>
</li>
</ul>
<form class="card p-2">
<div class="input-group">
<input type="text" class="form-control" placeholder="Promo code">
<div class="input-group-append">
<button type="submit" class="btn btn-secondary">Redeem</button>
</div>
</div>
</form>
</div>
<div class="col-md-8 order-md-1">
<h4 class="mb-3">Billing address</h4>
<form class="needs-validation" novalidate>
<div class="row">
<div class="col-md-6 mb-3">
<label for="firstName">First name</label>
<input type="text" class="form-control" id="firstName" placeholder="" value="" required>
<div class="invalid-feedback">
Valid first name is required.
</div>
</div>
<div class="col-md-6 mb-3">
<label for="lastName">Last name</label>
<input type="text" class="form-control" id="lastName" placeholder="" value="" required>
<div class="invalid-feedback">
Valid last name is required.
</div>
</div>
</div>
<div class="mb-3">
<label for="username">Username</label>
<div class="input-group">
<div class="input-group-prepend">
<span class="input-group-text">@</span>
</div>
<input type="text" class="form-control" id="username" placeholder="Username" required>
<div class="invalid-feedback" style="width: 100%;">
Your username is required.
</div>
</div>
</div>
<div class="mb-3">
<label for="email">Email <span class="text-muted">(Optional)</span></label>
<input type="email" class="form-control" id="email" placeholder="you@example.com">
<div class="invalid-feedback">
Please enter a valid email address for shipping updates.
</div>
</div>
<div class="mb-3">
<label for="address">Address</label>
<input type="text" class="form-control" id="address" placeholder="1234 Main St" required>
<div class="invalid-feedback">
Please enter your shipping address.
</div>
</div>
<div class="mb-3">
<label for="address2">Address 2 <span class="text-muted">(Optional)</span></label>
<input type="text" class="form-control" id="address2" placeholder="Apartment or suite">
</div>
<div class="row">
<div class="col-md-5 mb-3">
<label for="country">Country</label>
<select class="custom-select d-block w-100" id="country" required>
<option value="">Choose...</option>
<option>United States</option>
</select>
<div class="invalid-feedback">
Please select a valid country.
</div>
</div>
<div class="col-md-4 mb-3">
<label for="state">State</label>
<select class="custom-select d-block w-100" id="state" required>
<option value="">Choose...</option>
<option>California</option>
</select>
<div class="invalid-feedback">
Please provide a valid state.
</div>
</div>
<div class="col-md-3 mb-3">
<label for="zip">Zip</label>
<input type="text" class="form-control" id="zip" placeholder="" required>
<div class="invalid-feedback">
Zip code required.
</div>
</div>
</div>
<hr class="mb-4">
<div class="custom-control custom-checkbox">
<input type="checkbox" class="custom-control-input" id="same-address">
<label class="custom-control-label" for="same-address">Shipping address is the same as my billing address</label>
</div>
<div class="custom-control custom-checkbox">
<input type="checkbox" class="custom-control-input" id="save-info">
<label class="custom-control-label" for="save-info">Save this information for next time</label>
</div>
<hr class="mb-4">
<h4 class="mb-3">Payment</h4>
<div class="d-block my-3">
<div class="custom-control custom-radio">
<input id="credit" name="paymentMethod" type="radio" class="custom-control-input" checked required>
<label class="custom-control-label" for="credit">Credit card</label>
</div>
<div class="custom-control custom-radio">
<input id="debit" name="paymentMethod" type="radio" class="custom-control-input" required>
<label class="custom-control-label" for="debit">Debit card</label>
</div>
<div class="custom-control custom-radio">
<input id="paypal" name="paymentMethod" type="radio" class="custom-control-input" required>
<label class="custom-control-label" for="paypal">Paypal</label>
</div>
</div>
<div class="row">
<div class="col-md-6 mb-3">
<label for="cc-name">Name on card</label>
<input type="text" class="form-control" id="cc-name" placeholder="" required>
<small class="text-muted">Full name as displayed on card</small>
<div class="invalid-feedback">
Name on card is required
</div>
</div>
<div class="col-md-6 mb-3">
<label for="cc-number">Credit card number</label>
<input type="text" class="form-control" id="cc-number" placeholder="" required>
<div class="invalid-feedback">
Credit card number is required
</div>
</div>
</div>
<div class="row">
<div class="col-md-3 mb-3">
<label for="cc-expiration">Expiration</label>
<input type="text" class="form-control" id="cc-expiration" placeholder="" required>
<div class="invalid-feedback">
Expiration date required
</div>
</div>
<div class="col-md-3 mb-3">
<label for="cc-expiration">CVV</label>
<input type="text" class="form-control" id="cc-cvv" placeholder="" required>
<div class="invalid-feedback">
Security code required
</div>
</div>
</div>
<hr class="mb-4">
<button class="btn btn-primary btn-lg btn-block" type="submit">Continue to checkout</button>
</form>
</div>
</div>
<footer class="my-5 pt-5 text-muted text-center text-small">
<p class="mb-1">© 2020 Phoenix Hospital. All Rights Reserved.</p>
<ul class="list-inline">
<li class="list-inline-item"><a href="#">Privacy</a></li>
<li class="list-inline-item"><a href="#">Terms</a></li>
<li class="list-inline-item"><a href="#">Support</a></li>
</ul>
</footer>
</div><br>
<h3>Do not Reload Thid Page.</h3>
<script src="https://code.jquery.com/jquery-3.2.1.slim.min.js" integrity="sha384-KJ3o2DKtIkvYIK3UENzmM7KCkRr/rE9/Qpg6aAZGJwFDMVNA/GpGFF93hXpG5KkN" crossorigin="anonymous"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.12.9/umd/popper.min.js" integrity="sha384-ApNbgh9B+Y1QKtv3Rn7W3mgPxhU9K/ScQsAP7hUibX39j7fakFPskvXusvfa0b4Q" crossorigin="anonymous"></script>
<script src="https://maxcdn.bootstrapcdn.com/bootstrap/4.0.0/js/bootstrap.min.js" integrity="sha384-JZR6Spejh4U02d8jOt6vLEHfe/JQGiRRSQQxSfFWpi1MquVdAyjUar5+76PVCmYl" crossorigin="anonymous"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/holder/2.9.4/holder.min.js" integrity="sha256-ifihHN6L/pNU1ZQikrAb7CnyMBvisKG3SUAab0F3kVU=" crossorigin="anonymous"></script>
<script>
(function() {
'use strict';
window.addEventListener('load', function() {
var forms = document.getElementsByClassName('needs-validation');
var validation = Array.prototype.filter.call(forms, function(form) {
form.addEventListener('submit', function(event) {
if (form.checkValidity() === false) {
event.preventDefault();
event.stopPropagation();
}
form.classList.add('was-validated');
}, false);
});
}, false);
})();
</script>
</body>
</html>