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+@extends('layouts.pro-logged-in')
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+@section('content')
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+
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+ <h2 class="d-flex mb-3">
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+ <div>Bills: Add New</div>
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+ <div class="ml-auto">
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+ <a class="btn btn-primary btn-sm" href="{{route('bills-index')}}">
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+ <i class="fa fa-chevron-left" aria-hidden="true"></i>
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+ Back
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+ </a>
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+ </div>
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+ </h2>
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+
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+ <form action="/post-to-api"
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+ method="post" enctype="multipart/form-data"
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+ class="bg-light rounded border px-3 pt-3 mb-3">
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+ @csrf
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+
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+ @if (session('message'))
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+ <div class="alert alert-danger">{{ session('message') }}</div>
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+ @endif
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+
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+ <input type="hidden" name="_api" value="/api/bill/createForNote">
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+ <input type="hidden" name="_success" value="{{route('bills-index')}}">
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+ <input type="hidden" name="_return" value="{{route('bills-add_new')}}">
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+ <div class='form-group mb-3'>
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+<label class='control-label'>Note Uid</label>
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+<select class='form-control' name='noteUid' >
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+<option value=''>-- Select --</option>
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+<?php $dbOptions = \Illuminate\Support\Facades\DB::table('note')->get(); ?>
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+<?php foreach($dbOptions as $o): ?>
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+<option value='<?= $o->uid ?>'><?= $o->uid ?> (<?= $o->uid ?>)</option>
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+<?php endforeach; ?>
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+</select>
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Effective Date</label>
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+<input class='form-control' type='date' name='effectiveDate' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Code</label>
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+<input class='form-control' type='text' name='code' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Reason 1</label>
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+<input class='form-control' type='text' name='reason1' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Reason 2</label>
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+<input class='form-control' type='text' name='reason2' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Reason 3</label>
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+<input class='form-control' type='text' name='reason3' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Reason 3Plus</label>
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+<input class='form-control' type='text' name='reason3Plus' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Service Location</label>
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+<input class='form-control' type='text' name='serviceLocation' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Modifier</label>
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+<input class='form-control' type='text' name='modifier' >
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+</div>
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+<div class='form-group mb-3'>
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+<label class='control-label'>Number Of Units</label>
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+<input class='form-control' type='number' name='numberOfUnits' >
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+</div>
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+ <div class="form-group mb-3">
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+ <button class="btn btn-sm btn-primary mr-3 px-5">Submit</button>
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+ <a href="{{route('bills-index')}}" class="btn btn-sm btn-default px-5">Cancel</a>
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+ </div>
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+ </form>
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+
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+@endsection
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