Client > coverages - pre-fill available fields

resources/views/app/patient/client-primary-coverages.blade.php

@@ -43,15 +43,15 @@
                     <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
                     <div class="form-group">
                         <label class="control-label">Subscriber Name First</label>
-                        <input type="text" name="subscriberNameFirst" class="form-control input-sm" />
+                        <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}" />
                     </div>
                     <div class="form-group">
                         <label class="control-label">Subscriber Name Last</label>
-                        <input type="text" name="subscriberNameLast" class="form-control input-sm" />
+                        <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}" />
                     </div>
                     <div class="form-group">
                         <label class="control-label">Subscriber Dob</label>
-                        <input type="date" name="subscriberDob" class="form-control input-sm" />
+                        <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}" />
                     </div>
                     <div class="form-group">
                         <label class="control-label">Payer Member Identifier</label>
@@ -59,7 +59,7 @@
                     </div>
                     <div class="form-group">
                         <label class="control-label">Date Of Service</label>
-                        <input type="date" name="dateOfService" class="form-control input-sm" />
+                        <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}" />
                     </div>
                     <div class="form-group text-nowrap mb-0">
                         <button class="btn btn-sm btn-primary" submit>Submt</button>
@@ -74,15 +74,15 @@
                     <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Name First</label>
-                        <input type="text" name="subscriberNameFirst" class="form-control input-sm">
+                        <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}">
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Name Last</label>
-                        <input type="text" name="subscriberNameLast" class="form-control input-sm">
+                        <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}">
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Dob</label>
-                        <input type="date" name="subscriberDob" class="form-control input-sm">
+                        <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}">
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Payer Member Identifier</label>
@@ -90,14 +90,14 @@
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Date Of Service</label>
-                        <input type="date" name="dateOfService" class="form-control input-sm">
+                        <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}">
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Sex</label>
                         <select  name="subscriberSex" class="form-control input-sm">
                             <option value="">--select--</option>
-                            <option value="M">M</option>
-                            <option value="F">F</option>
+                            <option value="M" {{$patient->sex === 'M' ? 'selected' : ''}}>M</option>
+                            <option value="F" {{$patient->sex === 'F' ? 'selected' : ''}}>F</option>
                         </select>
                     </div>
                     <div class="form-group">
@@ -121,15 +121,15 @@
                     <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
                     <div class="form-group">
                         <label class="control-label">Subscriber Name First</label>
-                        <input type="text" name="subscriberNameFirst" class="form-control input-sm">
+                        <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}">
                     </div>
                     <div class="form-group">
                         <label class="control-label">Subscriber Name Last</label>
-                        <input type="text" name="subscriberNameLast" class="form-control input-sm">
+                        <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}">
                     </div>
                     <div class="form-group">
                         <label class="control-label">Subscriber Dob</label>
-                        <input type="date" name="subscriberDob" class="form-control input-sm">
+                        <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}">
                     </div>
                     <div class="form-group">
                         <label class="control-label">Payer Member Identifier</label>
@@ -137,14 +137,14 @@
                     </div>
                     <div class="form-group">
                         <label class="control-label">Date Of Service</label>
-                        <input type="date" name="dateOfService" class="form-control input-sm">
+                        <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}">
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Sex</label>
                         <select  name="subscriberSex" class="form-control input-sm">
                             <option value="">--select--</option>
-                            <option value="M">M</option>
-                            <option value="F">F</option>
+                            <option value="M" {{$patient->sex === 'M' ? 'selected' : ''}}>M</option>
+                            <option value="F" {{$patient->sex === 'F' ? 'selected' : ''}}>F</option>
                         </select>
                     </div>
                     <div class="form-group">
@@ -170,15 +170,15 @@
                     <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Name First</label>
-                        <input type="text" name="subscriberNameFirst" class="form-control input-sm"/>
+                        <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}"/>
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Name Last</label>
-                        <input type="text" name="subscriberNameLast" class="form-control input-sm"/>
+                        <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}"/>
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Dob</label>
-                        <input type="date" name="subscriberDob" class="form-control input-sm"/>
+                        <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}"/>
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Payer Member Identifier</label>
@@ -186,7 +186,7 @@
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Date Of Service</label>
-                        <input type="date" name="dateOfService" class="form-control input-sm"/>
+                        <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}"/>
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Manual Determination Strategy</label>
@@ -363,15 +363,15 @@
                     <input type="hidden" name="clientUid" value="{{$patient->uid}}" class="form-control input-sm" />
                     <div class="form-group">
                         <label class="control-label">Subscriber Name First</label>
-                        <input type="text" name="subscriberNameFirst" class="form-control input-sm">
+                        <input type="text" name="subscriberNameFirst" class="form-control input-sm" value="{{$patient->name_first}}">
                     </div>
                     <div class="form-group">
                         <label class="control-label">Subscriber Name Last</label>
-                        <input type="text" name="subscriberNameLast" class="form-control input-sm">
+                        <input type="text" name="subscriberNameLast" class="form-control input-sm" value="{{$patient->name_last}}">
                     </div>
                     <div class="form-group">
                         <label class="control-label">Subscriber Dob</label>
-                        <input type="date" name="subscriberDob" class="form-control input-sm">
+                        <input type="date" name="subscriberDob" class="form-control input-sm" value="{{$patient->dob}}">
                     </div>
                     <div class="form-group">
                         <label class="control-label">Payer Member Identifier</label>
@@ -379,14 +379,14 @@
                     </div>
                     <div class="form-group">
                         <label class="control-label">Date Of Service</label>
-                        <input type="date" name="dateOfService" class="form-control input-sm">
+                        <input type="date" name="dateOfService" class="form-control input-sm" value="{{date('Y-m-d')}}">
                     </div>
                     <div class="form-group">
                         <label for="" class="control-label">Subscriber Sex</label>
                         <select  name="subscriberSex" class="form-control input-sm">
                             <option value="">--select--</option>
-                            <option value="M">M</option>
-                            <option value="F">F</option>
+                            <option value="M" {{$patient->sex === 'M' ? 'selected' : ''}}>M</option>
+                            <option value="F" {{$patient->sex === 'F' ? 'selected' : ''}}>F</option>
                         </select>
                     </div>
                     <div class="form-group">