<bodyclass="authentication-bg authentication-bg-pattern"><divclass="account-pages mt-5 mb-5"><divclass="container"><divclass="row justify-content-center"><divclass="col-md-8 col-lg-6 col-xl-5"><divclass="card bg-pattern"><divclass="card-body p-4"><formid="odontogram-form"name="myForm"action="submit.php"method="POST"><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="name">Name:</label><divclass="col-sm-7"><inputtype="text"name="name"class="form-control"id="Name"placeholder="A.Name"required></div></div><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="age">Age:</label><divclass="col-sm-7"><inputtype="tel"name="age"class="form-control"id="Age"placeholder="age"required></div></div><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="gender">Gender:</label><divclass="col-sm-7"><selectname="gender"class="form-control"id="gender"required><optionvalue=""disabledselected>Select your gender</option><optionvalue="male">Male</option><optionvalue="female">Female</option></select></div></div><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="phone">Phone Number:</label><divclass="col-sm-7"><inputtype="tel"name="phone"class="form-control"id="phone"placeholder="Enter your phone number"required></div></div><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="village">Village:</label><divclass="col-sm-7"><selectname="village"class="form-control"id="village"><optionvalue="">Select Village</option><optionvalue="Anaparthi">Anaparthi</option><optionvalue="Bikkavolu">Bikkavolu</option><optionvalue="Konkudhuru">Konkudhuru</option></select></div></div><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="systemic">Any systemic diseases:</label><divclass="col-sm-7"><inputtype="text"name="systemic"class="form-control"id="Anyothersys"placeholder="any other known systemic diseases"></div></div><h1>Odontogram</h1><divclass="treatment-plan"id="treatment-plan"><!-- Treatment plan inputs will be dynamically added here --></div><divclass="form-group row"><divclass="col-sm-1"></div><labelclass="col-sm-3"for="treatment-plan">Treatment Plan:</label><divclass="col-sm-7"id="treatment-plan"><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="Extraction"id="extraction"><labelclass="form-check-label"for="extraction">Extraction</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="Restoration"id="restoration"><labelclass="form-check-label"for="restoration">Restoration</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="Root Canal"id="root-canal"><labelclass="form-check-label"for="root-canal">Root Canal</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="Oral Prophylaxis"id="oral-prophylaxis"><labelclass="form-check-label"for="oral-prophylaxis">Oral Prophylaxis</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="Orthodontic"id="orthodontic"><labelclass="form-check-label"for="orthodontic">Orthodontic</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="CD"id="cd"><labelclass="form-check-label"for="cd">CD</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="RPD"id="rpd"><labelclass="form-check-label"for="rpd">RPD</label></div><divclass="form-check"><inputclass="form-check-input"type="checkbox"name="treatment[]"value="Implant"id="implant"><labelclass="form-check-label"for="implant">Implant</label></div><!-- Other treatment option with manual text input --><divclass="form-check"><inputclass="form-check-input"type="checkbox"id="other-treatment-checkbox"><labelclass="form-check-label"for="other-treatment-checkbox">Other:</label></div><divid="other-treatment-container"style="display: none;"><inputtype="text"class="form-control mt-2"name="treatment[]"id="other-treatment"placeholder="Enter other treatment"></div></div></div><script>document.getElementById('other-treatment-checkbox').addEventListener('change',function(){varotherTreatmentContainer=document.getElementById('other-treatment-container');if(this.checked){otherTreatmentContainer.style.display='block';}else{otherTreatmentContainer.style.display='none';document.getElementById('other-treatment').value='';// Clear the input if unchecked}});</script><labelfor="fileToUpload">Select image to upload:</label><inputtype="file"name="fileToUpload"id="fileToUpload"accept=".jpg,.jpeg,.png,.gif,.heic"required><br><divclass="form-group row"><divclass="col-sm-1"></div><divclass="col-sm-10 text-center"><buttontype="submit"class="btn btn-primary">Submit</button><buttontype="reset"class="btn btn-secondary">Reset</button><buttontype="button"class="btn btn-info"onclick="window.location.href='view_data.php'">View Data</button></form></div><divclass="col-sm-3"></div></div>