<div moe wide>
    <a start show class="btn btn-primary text-white btn-sm mr-2"><i class="fas fa-plus"></i> Review Request</a>
    <form url="/api/clientReviewRequest/create" class="mcp-theme-1">
        <input type="hidden" name="clientUid" value="{{ $patient->uid }}">
        
        <div class="mb-2">
            <label class="font-weight-bold mb-1">Pro</label>
            <select provider-search name="proUid" class="form-control input-sm"></select>
        </div>
        <div class="mb-2">
            <label class="font-weight-bold mb-1">Scoped Month Start Date</label>
            <input type="date" class="form-control" name="scopedMonthStartDate" value="{{ date('Y-m-01') }}" />
        </div>
        <div class="mb-2">
            <label class="font-weight-bold mb-1">Access Start Date</label>
            <input type="date" class="form-control" name="accessStartDate" value="" />
        </div>
        <div class="mb-2">
            <label class="font-weight-bold mb-1">Access End Date</label>
            <input type="date" class="form-control" name="accessEndDate" value="" />
        </div>

        <div>
            <button submit class="btn btn-sm btn-primary mr-1">Submit</button>
            <button cancel class="btn btn-sm btn-default border">Cancel</button>
        </div>
    </form>
</div>