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@@ -23,7 +23,16 @@
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<input type="hidden" name="_api" value="/api/client/create">
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<input type="hidden" name="_success" value="{{route('my_clients-index')}}">
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<input type="hidden" name="_return" value="{{route('my_clients-add_new')}}">
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-
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+ <div class='form-group mb-3'><label class='control-label'>Team Uid</label><input class='form-control' type='text' name='teamUid'></div>
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+<div class='form-group mb-3'><label class='control-label'>Mcp Pro Uid</label><input class='form-control' type='text' name='mcpProUid'></div>
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+<div class='form-group mb-3'><label class='control-label'>Ally Pro Uid</label><input class='form-control' type='text' name='allyProUid'></div>
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+<div class='form-group mb-3'><label class='control-label'>Name Display</label><input class='form-control' type='text' name='nameDisplay'></div>
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+<div class='form-group mb-3'><label class='control-label'>Name</label><input class='form-control' type='text' name='name'></div>
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+<div class='form-group mb-3'><label class='control-label'>Gender</label><input class='form-control' type='text' name='gender'></div>
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+<div class='form-group mb-3'><label class='control-label'>Date Of Birth</label><input class='form-control' type='text' name='dateOfBirth'></div>
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+<div class='form-group mb-3'><label class='control-label'>Cell Number</label><input class='form-control' type='text' name='cellNumber'></div>
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+<div class='form-group mb-3'><label class='control-label'>Email Address</label><input class='form-control' type='text' name='emailAddress'></div>
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+<div class='form-group mb-3'><label class='control-label'>Medicare Number</label><input class='form-control' type='text' name='medicareNumber'></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('my_clients-index')}}" class="btn btn-sm btn-default px-5">Cancel</a>
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