<div class="stag-popup stag-popup-md mcp-theme-1" stag-popup-key="new-prescription-popup-REFERRAL">
    <form method="POST" action="" class="overflow-visible">
        <h3 class="stag-popup-title mb-2">
            <span>Referral Prescription</span>
            <a href="#" class="ml-auto text-secondary"
               onclick="return closeStagPopup()"><i class="fa fa-times-circle"></i></a>
        </h3>

        <div class="mb-2">
            <label class="text-sm text-secondary mb-1">Refer To</label>
            <input type="text" class="form-control form-control-sm min-width-unset"
                   v-model="newPrescription_REFERRAL.clinicalDetailJson.to">
        </div>
        <div class="mb-2">
            <label class="text-sm text-secondary mb-1">Memo</label>
            <input type="text" class="form-control form-control-sm min-width-unset"
                   v-model="newPrescription_REFERRAL.clinicalDetailJson.memo">
        </div>

        <div class="d-flex align-items-center justify-content-center mt-3">
            <button type="button" class="btn btn-sm btn-primary mr-2" v-on:click.prevent="saveNewPrescription()">Submit
            </button>
            <button type="button" class="btn btn-sm btn-default border" onclick="return closeStagPopup()">Cancel
            </button>
        </div>
    </form>
</div>
