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@@ -12,79 +12,67 @@
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<input autocomplete="_blank" type="text" name="patientNameSuffix" placeholder="Suffix" class="ml-2 mb-md-0 mb-2 form-control input-sm w-md-50">
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</div>
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</div>
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- <div class="col-md-12">
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- <div class="row form-group align-items-center">
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- <label class="col-md-3 font-weight-bold m-0">Email:</label>
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- <div class="col-md-9">
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- <input class='form-control' type='email' placeholder="Email Address" name='emailAddress'>
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+ <div class="col-md-12 p-0">
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+ <div class="col-md-6 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0">Email:</label>
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+ <input class='form-control ml-2' type='email' placeholder="Email Address" name='emailAddress'>
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</div>
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</div>
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</div>
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- <div class="col-md-12">
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- <div class="row form-group align-items-center">
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- <label class="col-md-3 font-weight-bold m-0">Gender:</label>
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- <div class="col-md-9">
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- <select class="form-control input-sm" name="patientSex" select2>
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- <option value="">--</option>
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- <option value="M">Male</option>
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- <option value="F">Female</option>
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- <option value="UNKNOWN">Unknown</option>
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- </select>
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- </div>
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+ <div class="col-md-12 p-0">
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+ <div class="col-md-4 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0 w-30">Gender:</label>
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+ <select class="form-control input-sm ml-2" name="patientSex" select2>
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+ <option value="">--</option>
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+ <option value="M">Male</option>
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+ <option value="F">Female</option>
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+ <option value="UNKNOWN">Unknown</option>
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+ </select>
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+ </div>
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</div>
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</div>
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</div>
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<div class="row">
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- <div class="col-12">
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- <div class="row form-group">
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- <label class="col-md-3 font-weight-bold m-0">DOB: <span class="text-danger">*</span></label>
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- <div class="col-md-9">
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- <input type="date" required name="patientDob" value="" class="form-control input-sm">
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- </div>
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+ <div class="col-md-5 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0 w-25">DOB: <span class="text-danger">*</span></label>
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+ <input type="date" required name="patientDob" value="" class="form-control input-sm">
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</div>
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</div>
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-
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- <div class="col-12">
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- <div class="row form-group">
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- <label class="col-md-3 font-weight-bold m-0">Service:</label>
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- <div class="col-md-9">
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- <input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
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- </div>
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+ <div class="col-md-5 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0 w-25">Service:</label>
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+ <input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
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</div>
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</div>
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-
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-
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-
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</div>
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@if($pro->pro_type === 'ADMIN')
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<div class="row">
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- <div class="col-12">
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- <div class="row form-group">
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- <label class="col-md-3 font-weight-bold m-0">HCP Pro:</label>
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- <div class="col-md-9">
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- <select name="hcpProUid" class="form-control input-sm" provider-search provider-type="hcp">
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- <option value="">--select--</option>
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- </select>
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- </div>
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+ <div class="col-md-5 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0 w-25">HCP Pro:</label>
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+ <select name="hcpProUid" class="form-control input-sm" provider-search provider-type="hcp">
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+ <option value="">--select--</option>
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+ </select>
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</div>
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</div>
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- <div class="col-12">
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- <div class="row form-group">
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- <label class='col-md-3 font-weight-bold m-0'>Coordinator:</label>
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- <div class="col-md-9">
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- <select name="assistantProUid" class="form-control input-sm" provider-search provider-type="default-na">
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- <option value="">--select--</option>
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- </select>
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- </div>
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+ <div class="col-md-7 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class='font-weight-bold m-0 w-25'>Coordinator:</label>
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+ <select name="assistantProUid" class="form-control input-sm ml-2" provider-search provider-type="default-na">
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+ <option value="">--select--</option>
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+ </select>
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</div>
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- </div>
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+ </div>
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</div>
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@elseif($pro->is_hcp === true)
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<div class="row">
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<div class="col-md-12">
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- <div class='row form-group'>
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- <label class="col-md-3 font-weight-bold m-0">HCP Pro:</label>
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- <div class="col-md-9">
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+ <div class='form-group'>
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0 w-25">HCP Pro:</label>
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<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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<input type="hidden" name="hcpProUid" value="{{$pro->uid}}">
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</div>
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@@ -93,34 +81,27 @@
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</div>
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@elseif($pro->isDefaultNA())
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<div class="row">
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- <div class="col-12">
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- <div class="row form-group">
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- <label class="col-md-3 font-weight-bold m-0">HCP Pro:</label>
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- <div class="col-md-9">
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- <?php $teams = $pro->teamsWhereAssistant; ?>
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- <select name="hcpProUid" class="form-control">
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- @if(count($teams) > 1)
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- <option value="">--select--</option>
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- @endif
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- @foreach($teams as $team)
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- <option value="{{$team->mcp->uid}}">{{$team->mcp->displayName()}}</option>
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- @endforeach
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- </select>
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- </div>
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+ <div class="col-md-5 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class="font-weight-bold m-0 w-25">HCP Pro:</label>
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+ <?php $teams = $pro->teamsWhereAssistant; ?>
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+ <select name="hcpProUid" class="form-control">
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+ @if(count($teams) > 1)
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+ <option value="">--select--</option>
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+ @endif
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+ @foreach($teams as $team)
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+ <option value="{{$team->mcp->uid}}">{{$team->mcp->displayName()}}</option>
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+ @endforeach
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+ </select>
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</div>
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</div>
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-
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- <div class="col-12">
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- <div class="row form-group">
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- <label class='col-md-3 font-weight-bold m-0'>Coordinator:</label>
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- <div class="col-md-9">
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- <input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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- <input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
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- </div>
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+ <div class="col-md-7 form-group">
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+ <div class="d-flex align-items-center">
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+ <label class='font-weight-bold m-0 w-25'>Coordinator:</label>
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+ <input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
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+ <input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
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</div>
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</div>
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-
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-
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</div>
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@endif
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<div class="row">
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@@ -164,4 +145,4 @@
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<input type='checkbox' name='isTestRecord' />
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This is a test record
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</label>
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-</div>
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+</div>
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