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@@ -122,6 +122,31 @@
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</div>
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</div>
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+ <hr class="m-negator-3 my-3">
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+ <div class="mt-3 mb-2">
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+ <div class="font-weight-bold mb-2">Basic Info</div>
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+ <div class="mb-1">
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+ Sex: <b>{{ $patient->sex ?? '' }}</b>
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+ <div moe wide>
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+ <a start show><i class="fa fa-edit"></i></a>
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+ <form url="/api/client/updateSex" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$patient->uid}}">
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Sex</label>
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+ <select class="form-control form-control-sm" name="sex">
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+ <option value="">--select--</option>
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+ <option value="M" @if($patient->sex === 'M') selected @endif>Male</option>
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+ <option value="F" @if($patient->sex === 'F') selected @endif>Female</option>
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+ </select>
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+ </div>
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+ <div>
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+ <button submit class="btn btn-sm btn-primary mr-1">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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+ </div>
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+ </div>
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<hr class="m-negator-3 my-3">
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<div class="d-flex align-items-center mt-3 mb-2">
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@@ -335,6 +360,86 @@
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</div>
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</div>
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+ <hr class="m-negator-3 my-3">
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+ <div class="mt-3 mb-2">
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+ <div class="font-weight-bold mb-2">Claim Details</div>
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+ <div class="mb-1">
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+ Claim Phone Number: <b>{{ $patient->claim_phone_number ?? '' }}</b>
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+ <div moe wide>
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+ <a start show><i class="fa fa-edit"></i></a>
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+ <form url="/api/client/updateClaimPhoneNumber" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$patient->uid}}">
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Claim Phone Number</label>
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+ <input type="text" class="form-control form-control-sm" name="claimPhoneNumber" />
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+ </div>
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+ <div>
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+ <button submit class="btn btn-sm btn-primary mr-1">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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+ </div>
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+ <div class="mb-1">
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+ <div class="d-flex">
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+ <span><b>Address</b> | </span>
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+ <div class="ml-1">
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+ <div moe wide>
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+ <a start show><i class="fa fa-edit"></i></a>
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+ <form url="/api/client/updateClaimAddress" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$patient->uid}}">
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Claim Address 1</label>
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+ <input type="text" class="form-control form-control-sm" value="{{ $patient->claim_address_line1 }}" name="claimAddressLine1" />
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+ </div>
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Claim Address 2</label>
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+ <input type="text" class="form-control form-control-sm" value="{{ $patient->claim_address_line2 }}" name="claimAddressLine2" />
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+ </div>
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+
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Claim Address City</label>
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+ <input type="text" class="form-control form-control-sm" value="{{ $patient->claim_address_city }}" name="claimAddressCity" />
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+ </div>
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+
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Claim Address State</label>
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+ <input type="text" class="form-control form-control-sm" value="{{ $patient->claim_address_state }}" name="claimAddressState" />
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+ </div>
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+
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+ <div class="mb-2">
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+ <label class="mb-1 text-secondary text-sm">Claim Address Zip</label>
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+ <input type="text" class="form-control form-control-sm" value="{{ $patient->claim_address_zip }}" name="claimAddressZip" />
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+ </div>
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+
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+ <div>
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+ <button submit class="btn btn-sm btn-primary mr-1">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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+ </div>
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+ </div>
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+ <div>
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+ Claim Address 1: <b>{{ $patient->claim_address_line1 ?? '' }}</b>
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+ </div>
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+ <div>
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+ Claim Address 2: <b>{{ $patient->claim_address_line2 ?? '' }}</b>
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+ </div>
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+ <div>
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+ Claim Address City: <b>{{ $patient->claim_address_city ?? '' }}</b>
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+ </div>
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+ <div>
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+ Claim Address State: <b>{{ $patient->claim_address_state ?? '' }}</b>
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+ </div>
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+ <div>
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+ Claim Address Zip: <b>{{ $patient->claim_address_zip ?? '' }}</b>
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+ </div>
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+
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+
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+ </div>
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+ </div>
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+
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</div>
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<div class="col-6 border-left">
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