|
@@ -14,16 +14,16 @@
|
|
</div>
|
|
</div>
|
|
<div class="col-md-12">
|
|
<div class="col-md-12">
|
|
<div class="row form-group align-items-center">
|
|
<div class="row form-group align-items-center">
|
|
- <label class="col-md-3 font-weight-bold m-0">Email:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <label class="col col-label font-weight-bold m-0">Email:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<input class='form-control' type='email' placeholder="Email Address" name='emailAddress'>
|
|
<input class='form-control' type='email' placeholder="Email Address" name='emailAddress'>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-md-12">
|
|
<div class="col-md-12">
|
|
<div class="row form-group align-items-center">
|
|
<div class="row form-group align-items-center">
|
|
- <label class="col-md-3 font-weight-bold m-0">Gender:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <label class="col-md-2 pr-0 font-weight-bold m-0">Gender:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<select class="form-control input-sm" name="patientSex" select2>
|
|
<select class="form-control input-sm" name="patientSex" select2>
|
|
<option value="">--</option>
|
|
<option value="">--</option>
|
|
<option value="M">Male</option>
|
|
<option value="M">Male</option>
|
|
@@ -36,18 +36,18 @@
|
|
</div>
|
|
</div>
|
|
<div class="row">
|
|
<div class="row">
|
|
<div class="col-12">
|
|
<div class="col-12">
|
|
- <div class="row form-group">
|
|
|
|
- <label class="col-md-3 font-weight-bold m-0">DOB: <span class="text-danger">*</span></label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <div class="row align-items-center form-group">
|
|
|
|
+ <label class="col-md-2 pr-0 font-weight-bold m-0">DOB: <span class="text-danger">*</span></label>
|
|
|
|
+ <div class="col-md-10">
|
|
<input type="date" required name="patientDob" value="" class="form-control input-sm">
|
|
<input type="date" required name="patientDob" value="" class="form-control input-sm">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="col-12">
|
|
<div class="col-12">
|
|
- <div class="row form-group">
|
|
|
|
- <label class="col-md-3 font-weight-bold m-0">Service:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <div class="row align-items-center form-group">
|
|
|
|
+ <label class="col-md-2 pr-0 font-weight-bold m-0">Service:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
|
|
<input type="date" name="dateOfService" value="{{date('Y-m-d')}}" class="form-control input-sm">
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
@@ -59,9 +59,9 @@
|
|
@if($pro->pro_type === 'ADMIN')
|
|
@if($pro->pro_type === 'ADMIN')
|
|
<div class="row">
|
|
<div class="row">
|
|
<div class="col-12">
|
|
<div class="col-12">
|
|
- <div class="row form-group">
|
|
|
|
- <label class="col-md-3 font-weight-bold m-0">HCP Pro:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <div class="row align-items-center form-group">
|
|
|
|
+ <label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<select name="hcpProUid" class="form-control input-sm" provider-search provider-type="hcp">
|
|
<select name="hcpProUid" class="form-control input-sm" provider-search provider-type="hcp">
|
|
<option value="">--select--</option>
|
|
<option value="">--select--</option>
|
|
</select>
|
|
</select>
|
|
@@ -69,9 +69,9 @@
|
|
</div>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
<div class="col-12">
|
|
<div class="col-12">
|
|
- <div class="row form-group">
|
|
|
|
- <label class='col-md-3 font-weight-bold m-0'>Coordinator:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <div class="row align-items-center form-group">
|
|
|
|
+ <label class='col-md-2 pr-0 font-weight-bold m-0' style="font-size:10px !important;">Coordinator:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<select name="assistantProUid" class="form-control input-sm" provider-search provider-type="default-na">
|
|
<select name="assistantProUid" class="form-control input-sm" provider-search provider-type="default-na">
|
|
<option value="">--select--</option>
|
|
<option value="">--select--</option>
|
|
</select>
|
|
</select>
|
|
@@ -83,8 +83,8 @@
|
|
<div class="row">
|
|
<div class="row">
|
|
<div class="col-md-12">
|
|
<div class="col-md-12">
|
|
<div class='row form-group'>
|
|
<div class='row form-group'>
|
|
- <label class="col-md-3 font-weight-bold m-0">HCP Pro:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
|
|
<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
|
|
<input type="hidden" name="hcpProUid" value="{{$pro->uid}}">
|
|
<input type="hidden" name="hcpProUid" value="{{$pro->uid}}">
|
|
</div>
|
|
</div>
|
|
@@ -94,9 +94,9 @@
|
|
@elseif($pro->isDefaultNA())
|
|
@elseif($pro->isDefaultNA())
|
|
<div class="row">
|
|
<div class="row">
|
|
<div class="col-12">
|
|
<div class="col-12">
|
|
- <div class="row form-group">
|
|
|
|
- <label class="col-md-3 font-weight-bold m-0">HCP Pro:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <div class="row align-items-center form-group">
|
|
|
|
+ <label class="col-md-2 pr-0 font-weight-bold m-0">HCP Pro:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<?php $teams = $pro->teamsWhereAssistant; ?>
|
|
<?php $teams = $pro->teamsWhereAssistant; ?>
|
|
<select name="hcpProUid" class="form-control">
|
|
<select name="hcpProUid" class="form-control">
|
|
@if(count($teams) > 1)
|
|
@if(count($teams) > 1)
|
|
@@ -111,9 +111,9 @@
|
|
</div>
|
|
</div>
|
|
|
|
|
|
<div class="col-12">
|
|
<div class="col-12">
|
|
- <div class="row form-group">
|
|
|
|
- <label class='col-md-3 font-weight-bold m-0'>Coordinator:</label>
|
|
|
|
- <div class="col-md-9">
|
|
|
|
|
|
+ <div class="row align-items-center form-group">
|
|
|
|
+ <label class='col-md-2 pr-0 font-weight-bold m-0'>Coordinator:</label>
|
|
|
|
+ <div class="col-md-10">
|
|
<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
|
|
<input type="text" class="form-control" readonly value="{{$pro->displayName()}}">
|
|
<input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
|
|
<input type="hidden" name="assistantProUid" value="{{$pro->uid}}">
|
|
</div>
|
|
</div>
|