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+@extends ('layouts.template')
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+
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+@section('content')
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+
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+ <?php $patients = [1,2,3,4]; ?>
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+
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+ <div class="p-3 mcp-theme-1" id="newPatientContainer">
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+ <div class="col-12 col-lg-6 px-0">
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+ <div class="card d-block mb-3" moe="">
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+
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+ <div class="card-header">
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+ <strong>
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+ <i class="fas fa-user-plus"></i>
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+ New Patient
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+ </strong>
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+ </div>
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+ <div class="card-body">
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+ <form show url="/api/client/createNonMcn" class="px-3 pt-3 pb-1 primary-form" redir="patients/view/[data]">
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+ @if (session('message'))
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+ <div class="alert alert-danger">{{ session('message') }}</div>
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+ @endif
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>How is quarantine treating you?</label>
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+ <textarea class='form-control' type='text' name='howIsQuarantine'></textarea>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>First Name *</label>
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+ <input class='form-control' type='text' name='nameFirst' required>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Last Name *</label>
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+ <input class='form-control' type='text' name='nameLast' value='' required>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Sex</label>
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+ <select class='form-control' name='sex' value='' >
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+ <option value=''>-- Select --</option>
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+ <option value='M'>M</option>
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+ <option value='F'>F</option>
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+ </select>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Date Of Birth *</label>
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+ <input class='form-control' type='date' name='dateOfBirth' max="{{ date('Y-m-d') }}" required>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label d-flex align-items-center'>
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+ <span>Home Phone Number</span>
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+ <a href="#"
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+ class="ml-2 px-1 on-hover-opaque hpn-to-cpn">
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+ <i class="fa fa-arrow-down"></i>
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+ </a>
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+ <a href="#"
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+ class="ml-2 px-1 on-hover-opaque swap-pns">
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+ <i class="fa fa-retweet"></i>
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+ </a>
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+ </label>
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+ <input class='form-control' stag-input-phone type='tel' name='homeNumber'>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label d-flex align-items-center'>
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+ <span>Cell Phone Number</span>
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+ <a href="#"
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+ class="ml-2 px-1 on-hover-opaque cpn-to-hpn">
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+ <i class="fa fa-arrow-up"></i>
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+ </a>
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+ </label>
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+ <input class='form-control' stag-input-phone type='tel' name='cellNumber'>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Email Address </label>
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+ <input class='form-control' type='email' name='emailAddress'>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Payer</label>
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+ <select name="mbPayerUid" class="form-control select2">
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+ <option value="">--select--</option>
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+ @foreach($mbPayers as $mbPayer)
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+ <option value="{{$mbPayer->uid}}">{{$mbPayer->name()}}</option>
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+ @endforeach
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+ </select>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Member ID</label>
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+ <input class='form-control' type='text' name='mbPayerMemberId' required>
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+ </div>
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+ <div class='form-group mb-3'>
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+ <label class='control-label'>Initiative</label>
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+ <select name="initiative" class="form-control ">
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+ <option value="">-- select --</option>
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+ @foreach($intiatives as $initiative)
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+ <option value="{{$initiative}}">{{$initiative}}</option>
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+ @endforeach
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+ </select>
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+ </div>
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+ </form>
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+ </div>
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+ <div class="card-footer">
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+ <button class="btn btn-primary" submit>Create New Patient</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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+
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+ <link href="/select2/select2.min.css" rel="stylesheet" />
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+ <script src="/select2/select2.min.js"></script>
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+ <script src="/inputmask-5.x/dist/inputmask.js"></script>
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+ <script>
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+ (function() {
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+ function init() {
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+ let im = new Inputmask("(999) 999-9999").mask('[stag-input-phone]');
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+ $(document)
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+ .off('click.hpn-to-cpn', '.hpn-to-cpn')
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+ .on('click.hpn-to-cpn', '.hpn-to-cpn', function() {
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+ $('[name="cellNumber"]').val($('[name="homeNumber"]').val());
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+ $('[name="homeNumber"]').val('');
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+ return false;
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+ });
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+ $(document)
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+ .off('click.cpn-to-hpn', '.cpn-to-hpn')
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+ .on('click.cpn-to-hpn', '.cpn-to-hpn', function() {
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+ $('[name="homeNumber"]').val($('[name="cellNumber"]').val());
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+ $('[name="cellNumber"]').val('');
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+ return false;
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+ });
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+ $(document)
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+ .off('click.swap-pns', '.swap-pns')
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+ .on('click.swap-pns', '.swap-pns', function() {
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+ let hpn = $('[name="homeNumber"]').val();
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+ $('[name="homeNumber"]').val($('[name="cellNumber"]').val());
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+ $('[name="cellNumber"]').val(hpn);
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+ return false;
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+ });
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+ $('.select2').select2();
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+ }
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+ addMCInitializer('new-patient', init, '#newPatientContainer');
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+ }).call(window);
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+ </script>
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+
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+@endsection
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