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@@ -13,15 +13,15 @@
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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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+ <div class="row form-group align-items-center">
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<label class="col col-label font-weight-bold m-0">Email:</label>
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- <div class="col-md-10">
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+ <div class="col-md-10">
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<input class='form-control' 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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+ <div class="row form-group align-items-center">
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<label class="col-md-2 pr-0 font-weight-bold m-0">Gender:</label>
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<div class="col-md-10">
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<select class="form-control input-sm" name="patientSex" select2>
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@@ -38,30 +38,30 @@
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<div class="col-12">
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<div class="row align-items-center form-group">
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<label class="col-md-2 pr-0 font-weight-bold m-0">DOB: <span class="text-danger">*</span></label>
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- <div class="col-md-10">
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+ <div class="col-md-10">
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<input type="date" required name="patientDob" value="" class="form-control input-sm" max="{{date('Y-m-d')}}">
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</div>
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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 align-items-center form-group">
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+ <div class="row align-items-center form-group">
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<label class="col-md-2 pr-0 font-weight-bold m-0">Service:</label>
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- <div class="col-md-10">
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+ <div class="col-md-10">
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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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</div>
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-
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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 align-items-center form-group">
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+ <div class="row align-items-center form-group">
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<label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
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- <div class="col-md-10">
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+ <div class="col-md-10">
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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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@@ -69,7 +69,7 @@
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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 align-items-center form-group">
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+ <div class="row align-items-center form-group">
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<label class='col-md-2 pr-0 font-weight-bold m-0' style="font-size:10px !important;">Coordinator:</label>
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<div class="col-md-10">
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<select name="assistantProUid" class="form-control input-sm" provider-search provider-type="default-na">
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@@ -77,14 +77,14 @@
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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>
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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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+ <div class='row form-group'>
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<label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
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- <div class="col-md-10">
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+ <div class="col-md-10">
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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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@@ -104,7 +104,7 @@
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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 align-items-center form-group">
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+ <div class="row align-items-center form-group">
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<label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
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<div class="col-md-10">
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<?php $teams = $pro->teamsWhereAssistant; ?>
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@@ -121,16 +121,16 @@
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</div>
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<div class="col-12">
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- <div class="row align-items-center form-group">
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+ <div class="row align-items-center form-group">
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<label class='col-md-2 pr-0 font-weight-bold m-0'>Coordinator:</label>
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- <div class="col-md-10">
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+ <div class="col-md-10">
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<input type="text" class="form-control" readonly value="{{$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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</div>
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-
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-
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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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@@ -169,16 +169,18 @@
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<input class='form-control' type='text' name='source' />
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</div>
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-<div class='form-group mb-3 checkbox'>
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- <label>
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- <input type='checkbox' name='forceNewChartCreation' />
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- Force New Chart Creation
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- </label>
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-</div>
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+<div class="row m-0">
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+ <div class='form-group mb-3 checkbox'>
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+ <label class="d-flex align-items-center">
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+ <input type='checkbox' name='forceNewChartCreation' class="mr-2" />
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+ Force New Chart Creation
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+ </label>
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+ </div>
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-<div class='form-group mb-3 checkbox'>
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- <label>
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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 class='form-group mb-3 ml-3 checkbox'>
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+ <label class="d-flex align-items-center">
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+ <input type='checkbox' name='isTestRecord' class="mr-2" />
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+ <b>Test Record</b>
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+ </label>
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+ </div>
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</div>
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