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