rawat jalan

//--daftar.php
<form method = "POST" action = "transaksi/rajal/rajal_simpan.php">
<fieldset>
<legend>DAFTAR RAWAT JALAN</legend>
<table border="0" cellspacing="10" width="100%" class="form">
<tr>
<td width="200">No Rekam Medis</td>
<td><input type="text" name="id" size="6" value="<?php echo $data['id'];?>" readonly>
</tr>
<tr>
<td>Nama Lengkap</td>
<td>: <?php echo $data['nama'];?></td>
</tr>
<tr>
<td>Alamat</td>
<td>: <?php echo $data['alamat'].', '.$data['kecamatan'].', '.$data['kabupaten'];?></td>
</tr>
<tr>
<td>Tanggal Lahir</td>
<td>: <?php echo $data['tanggal_lahir'];?></td>
</tr>
<tr>
<td>Jenis Kelamin</td>
<td>:
<?php echo ($data['gender'] == 1)?"Laki-laki":"Perempuan"; ?>
</td>
</tr>
<tr>
<td width="200">Poli yang dituju</td>
<td>
<select name="poli">
<option value="">Pilih Poli</option>
<option value="Sp. Penyakit Dalam">Sp. Penyakit Dalam</option>
<option value="Sp. Saraf">Sp. Saraf</option>
<option value="Umum">Umum</option>
<option value="Fisioteraphy">Fisioteraphy</option>
</select>
</tr>
<tr>
<td width="200">Cara Bayar</td>
<td>
<select name="bayar">
<option value="">Pilih Cara Bayar</option>
<option value="BPJS">BPJS</option>
<option value="ASKES">ASKES</option>
<option value="JAMKESMAS">JAMKESMAS</option>
<option value="JAMKESDA">JAMKESDA</option>
<option value="JAMKESTA">JAMKESOS</option>
<option value="UMUM">BAYAR</option>
</select>
</tr>
<tr>
<td>Jenis Pasien</td>
<td><input type="radio" name="jpas" value="L" checked>Pasien Lama
<input type="radio" name="jpas" value="B">Pasien Baru</td>
</tr>
<tr>
<td>Catatan</td>
<td><textarea name="catatan" cols="40" rows="2" ></textarea></td>
</tr>
<tr>
<td></td>
<td>
<input type="submit" name="submit" value="Daftar">
<input type="reset" name="reset" value="Set Ulang">
</td>
</tr>
</table>
</form>

//== simpan.php ===
<?php
include "../../config/connection.php";
// buat query untuk menyimpan data (insert data)
$sql = "INSERT INTO p_rajal (id, poli, bayar, jpas, catatan)
    VALUES ('{$_POST['id']}','{$_POST['poli']}','{$_POST['bayar']}','{$_POST['jpas']}','{$_POST['catatan']}')";
// jalankan query
$query = mysql_query($sql);
header('location:../../index.php?page=register_rajal&status='.($query?'sukses':'failed'));
?>