create.blade.php 2.6 KB

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  1. @extends('layouts.pro')
  2. @section('content')
  3. <h1>Create pro</h1>
  4. <div moe>
  5. <form url="/api/pro/create" redir="/pros/show/" method="POST">
  6. <div class="form-group">
  7. <label class="control-label">cellNumber</label>
  8. <input type=cellNumber"text" class="form-control">
  9. </div>
  10. <div class="form-group">
  11. <label class="control-label">emailAddress</label>
  12. <input name="emailAddress" type="email" class="form-control">
  13. </div>
  14. <div class="form-group">
  15. <label class="control-label">nameDisplay</label>
  16. <input type="text" name="name.nameDisplay" class="form-control">
  17. </div>
  18. <div class="form-group">
  19. <label class="control-label">namePrefix</label>
  20. <input type="text" name="name.namePrefix" class="form-control">
  21. </div>
  22. <div class="form-group">
  23. <label class="control-label">nameFirst</label>
  24. <input type="text" name="name.nameFirst" class="form-control">
  25. </div>
  26. <div class="form-group">
  27. <label class="control-label">nameMiddle</label>
  28. <input type="text" name="name.nameMiddle" class="form-control">
  29. </div>
  30. <div class="form-group">
  31. <label class="control-label">nameLast</label>
  32. <input type="text" name="name.nameLast" class="form-control">
  33. </div>
  34. <div class="form-group">
  35. <label class="control-label">nameSuffix</label>
  36. <input type="text" name="name.nameSuffix" class="form-control">
  37. </div>
  38. <div class="form-group">
  39. <label class="control-label">nameCredential</label>
  40. <input type="text" name="name.nameCredential" class="form-control">
  41. </div>
  42. <div class="form-group">
  43. <label class="control-label">isHcp</label>
  44. <input name="isHcp" type="checkbox" class="form-control">
  45. </div>
  46. <div class="form-group">
  47. <label class="control-label">hcpNpi</label>
  48. <input name="hcpNpi" type="text" class="form-control">
  49. </div>
  50. <div class="form-group">
  51. <label class="control-label">previousProfessionCategory</label>
  52. <input name="previousProfessionCategory" type="text" class="form-control">
  53. </div>
  54. <div class="form-group">
  55. <label class="control-label">currentProfessionCategory</label>
  56. <input name="currentProfessionCategory" type="text" class="form-control">
  57. </div>
  58. <div class="form-group">
  59. <button submit>Submit</button>
  60. </div>
  61. </form>
  62. </div>
  63. @endsection