167 lines
8.6 KiB
PHP
167 lines
8.6 KiB
PHP
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<!-- end app-header -->
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<!-- begin app-container -->
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<div class="app-container">
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<!-- begin app-nabar -->
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<aside class="app-navbar">
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<? include "application/views/template/menu/sidemain.php"; ?>
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</aside>
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<!-- end app-navbar -->
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<!-- begin app-main -->
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<div class="app-main" id="main">
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<!-- begin container-fluid -->
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<div class="container-fluid">
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<? include "application/views/template/topstrip.php"; ?>
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<!-- begin row -->
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<div class="row">
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<div class="col-lg-6 col-xxl-4 m-b-30">
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<div class="card card-statistics h-100 mb-0">
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<div class="card-header d-flex justify-content-between">
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<div class="card-heading">
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<h4 class="card-title">New Patient</h4>
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</div>
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<div class="dropdown">
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<!-- a class="btn btn-round btn-inverse-primary btn-xs" href="#">View all </a -->
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</div>
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</div>
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<div class="card-body">
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<div class="card-body">
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<form method="POST" action="/patient/addnew">
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<div class="form-row">
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<div class="form-group col-md-6">
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<label for="inputEmail4">Firstname</label>
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<input type="text" class="form-control" id="firstname" name="firstname" value="<?=$firstname?>" placeholder="Firstname">
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</div>
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<div class="form-group col-md-6">
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<label for="inputPassword4">Lastname</label>
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<input type="text" class="form-control" id="lastname" name="lastname" value="<?=$lastname?>" placeholder="Lastname">
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</div>
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</div>
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<div class="form-row">
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<div class="form-group col-md-6">
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<label for="inputEmail4">Email</label>
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<input type="email" class="form-control" id="inputEmail4" placeholder="Email">
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</div>
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<div class="form-group col-md-6">
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<label for="inputPassword4">Password</label>
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<input type="password" class="form-control" id="password" value="<?=$password?>" placeholder="Password">
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</div>
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</div>
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<div class="form-group">
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<label for="inputAddress">Address</label>
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<input type="text" class="form-control" id="street1" name="street1" value="<?=$street1?>" placeholder="1234 Main St">
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</div>
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<div class="form-group">
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<label for="inputAddress2">Address 2</label>
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<input type="text" class="form-control" id="street2" name="street2" value="<?=$street2?>" placeholder="Apartment, studio, or floor">
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</div>
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<div class="form-row">
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<div class="form-group col-md-6">
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<label for="inputCity">City</label>
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<input type="text" class="form-control" id="city" name="city" value="<?=$city?>">
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</div>
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<div class="form-group col-md-4">
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<label for="inputState">State</label>
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<select id="inputState" class="form-control" name="state">
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<option selected>Select State</option>
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<option value="OGUN">Ogun</option>
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<option value="OYO">Oyo</option>
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<option value="OSUN" selected>Osun</option>
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</select>
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</div>
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<div class="form-group col-md-2">
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<label for="inputZip">Zip</label>
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<input type="text" class="form-control" id="zipcode" name="zipcode" value="<?=$zipcode?>">
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</div>
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</div>
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<div class="form-group">
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<div class="form-check">
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<label class="form-check-label">
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<?=$account_message?>
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</label>
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</div>
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</div>
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<div class="form-row">
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<div class="form-group col-md-9">
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</div>
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<div class="form-group col-md-3">
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<button type="submit" class="btn btn-primary">Add Patient</button>
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</div>
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</div>
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</form>
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</div>
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</div>
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</div>
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</div>
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<div class="col-xxl-8 m-b-30">
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<? include 'application/views/provider/components/patient_listing.php'; ?>
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</div>
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</div>
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<!-- end row -->
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<!-- event Modal -->
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<div class="modal fade" id="eventModal" tabindex="-1" role="dialog" aria-labelledby="verticalCenterTitle" aria-hidden="true">
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<div class="modal-dialog modal-dialog-centered" role="document">
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<div class="modal-content">
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<div class="modal-header">
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<h5 class="modal-title" id="verticalCenterTitle">Add New Event</h5>
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<button type="button" class="close" data-dismiss="modal" aria-label="Close">
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<span aria-hidden="true">×</span>
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</button>
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</div>
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<div class="modal-body">
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<form>
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<div class="form-group">
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<label for="modelemail">Event Name</label>
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<input type="email" class="form-control" id="modelemail">
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</div>
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<div class="form-group">
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<label>Choose Event Color</label>
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<select class="form-control">
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<option>Primary</option>
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<option>Warning</option>
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<option>Success</option>
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<option>Danger</option>
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</select>
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</div>
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</form>
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</div>
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<div class="modal-footer">
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<button type="button" class="btn btn-danger" data-dismiss="modal">Close</button>
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<button type="button" class="btn btn-success">Save changes</button>
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</div>
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</div>
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</div>
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</div>
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</div>
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<!-- end container-fluid -->
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</div>
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<!-- end app-main -->
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</div>
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<!-- end app-container -->
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<!-- begin footer -->
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