CHIEFSOFT\ameye
133 lines
6.4 KiB
PHP
133 lines
6.4 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>
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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" 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" 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="inputPassword4" 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="inputAddress" 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="inputAddress2" 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="inputCity">
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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">
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<option selected>Select State</option>
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<option>Ontario</option>
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<option>Toronto</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="inputZip">
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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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<input class="form-check-input" type="checkbox" id="gridCheck">
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<label class="form-check-label" for="gridCheck">
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Check me out
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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-20">
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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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</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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