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@@ -129,15 +129,31 @@
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None provided.
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@endif
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</a>
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- <form url="/api/client/putMcn">
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+ <form url="/api/client/putMcn" class="mcp-theme-1">
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<input type="hidden" name="uid" value="{{$patient->uid}}">
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- <input type="text" name="name_first" value="{{$patient->name_first}}">
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- <input type="text" name="name_last" value="{{$patient->name_last}}">
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- <input type="text" name="dob" value="{{$patient->dob}}">
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- <input type="text" name="mcn" value="{{$patient->mcn}}">
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+ <div class="mb-2">
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+ <input type="text" class="form-control form-control-sm" name="name_first"
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+ value="{{$patient->name_first}}"
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+ placeholder="First Name">
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+ </div>
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+ <div class="mb-2">
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+ <input type="text" class="form-control form-control-sm" name="name_last"
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+ value="{{$patient->name_last}}"
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+ placeholder="Last Name">
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+ </div>
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+ <div class="mb-2">
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+ <input type="date" class="form-control form-control-sm" name="dob"
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+ value="{{$patient->dob}}"
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+ placeholder="Date of Birth">
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+ </div>
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+ <div class="mb-2">
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+ <input type="text" class="form-control form-control-sm" name="mcn"
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+ value="{{$patient->mcn}}"
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+ placeholder="Medicare Number">
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+ </div>
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<div>
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- <button submit>Submit</button>
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- <button cancel>Cancel</button>
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+ <button submit class="btn btn-sm btn-primary mr-2">Submit</button>
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+ <button cancel class="btn btn-sm btn-default border">Cancel</button>
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</div>
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</form>
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</div>
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@@ -389,16 +405,14 @@
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@if(!$patient->was_medicare_validation_successful)
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<div moe>
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<a href="" start show><i class="fas fa-edit"></i></a>
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- <form url="/api/client/putMcn">
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+ <form url="/api/client/putMcn" class="mcp-theme-1">
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<input type="hidden" name="uid" value="{{$patient->uid}}">
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<div class="form-group">
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- <input type="text" name="mcn" value="{{$patient->mcn}}">
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+ <input type="text" class="form-control form-control-sm" name="mcn" value="{{$patient->mcn}}">
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</div>
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- <div class="form-group">
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- <button class="btn btn-success btn-sm" submit>Submit
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- </button>
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- <button class="btn btn-secondary btn-sm" cancel>Cancel
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- </button>
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+ <div>
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+ <button submit class="btn btn-sm btn-primary mr-2">Submit</button>
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+ <button cancel class="btn btn-sm btn-default border">Cancel</button>
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</div>
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</form>
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</div>
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