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@@ -270,48 +270,81 @@
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<i class="fa fa-plus-circle"></i>
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<i class="fa fa-plus-circle"></i>
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Note
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Note
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</a>
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</a>
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- <form url="/api/note/createUsingFreeTextHtml" right>
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+ <form url="/api/note/create" right>
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<input type="hidden" name="clientUid" value="{{$patient->uid}}">
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<input type="hidden" name="clientUid" value="{{$patient->uid}}">
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- <div class="form-group">
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- <label for="" class="control-label">HCP Pro</label>
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- <select name="hcpProUid" class="form-control">
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- <option value="">-- select hcp pro --</option>
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- @foreach ($pros as $pro)
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- <option
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- value="{{$pro->uid}}">{{$pro->name_display}}</option>
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- @endforeach
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- </select>
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- </div>
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- <div class="form-group">
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- <label for="" class="control-label">Ally Pro</label>
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- <select name="allyProUid" class="form-control">
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- <option value="">-- select ally pro --</option>
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- @foreach ($pros as $pro)
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- <option
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- value="{{$pro->uid}}">{{$pro->name_display}}</option>
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- @endforeach
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- </select>
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- </div>
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- <div class="form-group">
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- <label for="" class="control-label text-left">Title</label>
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- <input type="text" name="title" class="form-control">
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- </div>
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- <div class="form-group">
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- <label for="" class="control-label text-left">Effective date</label>
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- <input type="date" name="effectiveDateEST" class="form-control">
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- </div>
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-
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- <div class="form-group">
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- <label for="" class="control-label text-left">Effective time</label>
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- <input type="time" name="effectiveTime" class="form-control">
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- </div>
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-
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- <div class="form-group">
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- <textarea name="freeTextHtml" id="" cols="30" rows="10" class="form-control"></textarea>
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- </div>
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- <div class="form-group">
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- <button class="btn btn-primary" submit>Submit</button>
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- <button class="btn btn-danger" cancel>Cancel</button>
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+ <div class="row">
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label for="" class="control-label">HCP Pro</label>
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+ <select name="hcpProUid" class="form-control">
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+ <option value="">-- select hcp pro --</option>
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+ @foreach ($pros as $pro)
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+ <option
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+ value="{{$pro->uid}}">{{$pro->name_display}}</option>
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+ @endforeach
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label">Ally Pro</label>
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+ <select name="allyProUid" class="form-control">
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+ <option value="">-- select ally pro --</option>
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+ @foreach ($pros as $pro)
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+ <option
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+ value="{{$pro->uid}}">{{$pro->name_display}}</option>
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+ @endforeach
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+ </select>
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label text-left">Title</label>
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+ <input type="text" name="title" class="form-control">
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+ </div>
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+ <div class="form-group">
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+ <label for="" class="control-label text-left">Effective date</label>
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+ <input type="date" name="effectiveDateEST" class="form-control">
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+ </div>
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+
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+ <div class="form-group">
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+ <label for="" class="control-label text-left">Effective time</label>
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+ <input type="time" name="effectiveTime" class="form-control">
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+ </div>
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+ </div>
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+ <div class="col-md-6">
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+ <div class="form-group">
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+ <label for="" class="control-label">reason1</label>
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+ <input type="text" name="reason1" class="form-control">
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+ </div>
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+
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+ <div class="form-group">
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+ <label for="" class="control-label">reason2</label>
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+ <input type="text" name="reason2" class="form-control">
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+ </div>
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+
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+ <div class="form-group">
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+ <label for="" class="control-label">reason3</label>
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+ <input type="text" name="reason3" class="form-control">
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+ </div>
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+
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+ <div class="form-group">
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+ <label for="" class="control-label">reason3Plus</label>
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+ <input type="text" name="reason3Plus" class="form-control">
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+ </div>
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+
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+ <div class="form-group">
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+ <label for="" class="control-label">serviceLocation</label>
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+ <input type="text" name="serviceLocation" class="form-control">
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+ </div>
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+
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+ <div class="form-group">
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+ <label for="" class="control-label">category</label>
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+ <input type="text" name="category" class="form-control">
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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="form-group">
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+ <button class="btn btn-primary" submit>Submit</button>
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+ <button class="btn btn-danger" cancel>Cancel</button>
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+ </div>
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+ </div>
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</div>
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</div>
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</form>
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</form>
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</div>
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</div>
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