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@@ -56,17 +56,51 @@
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<div class="ml-3">
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<div class="d-inline-flex align-items-start">
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<b>{{ ucwords($patient->is_enrolled_in_rm ? $patient->is_enrolled_in_rm : '-') }}</b>
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- <div moe class="ml-2">
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- <a start show>Toggle</a>
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- <form url="/api/client/{{$patient->is_enrolled_in_rm === 'YES' ? 'setIsEnrolledInRmToFalse' : 'setIsEnrolledInRmToTrue'}}" class="mcp-theme-1">
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- <input type="hidden" name="uid" value="{{$patient->uid}}">
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- <p>Toggle RM enrollment?</p>
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- <div>
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- <button submit class="btn btn-sm btn-primary mr-1">Submit</button>
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- <button cancel class="btn btn-sm btn-default border">Cancel</button>
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- </div>
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- </form>
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- </div>
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+ @if($patient->is_enrolled_in_rm === 'YES')
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+ <div moe wide class="ml-2">
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+ <a start show>Toggle</a>
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+ <form url="/api/client/setIsEnrolledInRmToFalse" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$patient->uid}}">
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+ <h2 class="alert alert-warning"><i class="fa fa-warning"></i> RPM Enrollment Cancellation</h2>
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+ <div>
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+ <button submit class="btn btn-sm btn-primary mr-1">Submit</button>
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+ <button cancel class="btn btn-sm btn-default border">Cancel</button>
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+ </div>
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+ </form>
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+ </div>
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+ @else
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+ <div moe wide class="ml-2">
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+ <a start show>Toggle</a>
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+ <form url="/api/client/setIsEnrolledInRmToTrue" class="mcp-theme-1">
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+ <input type="hidden" name="uid" value="{{$patient->uid}}">
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+ <h2>RPM Enrollment:</h2>
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+ <h3>Please confirm the following with patient:</h3>
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+ <p>I understand that:</p>
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+ <ul>
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+ <li>
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+ <input type="checkbox" required="true" name="x" class="form-control input-sm">
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+ I am the only person who should be using the remote monitoring equipment as instructed. I will
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+ not use the device for reasons other than my own personal health monitoring. I understand that
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+ I can only participate in this program with one Medical Provider at a time.
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+ </li>
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+ <li>
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+ <input type="checkbox" required="true" name="y" class="form-control input-sm">
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+ I will not tamper with the equipment. I understand that I am responsible for any fees associated
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+ with misuse of the equipment.
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+ </li>
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+ <li>
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+ <input type="checkbox" required="true" name="z" class="form-control input-sm">
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+ I understand the devices are only designed for the RPM program.
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+ </li>
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+ </ul>
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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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+ @endif
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</div>
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</div>
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</div>
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