<!DOCTYPE html>
<html lang="{{ str_replace('_', '-', app()->getLocale()) }}">
<head>
  @include('layout.header')
  <link rel="stylesheet" href="{{ asset('assets/vendors/select2/select2.min.css') }}">
</head>
<body>
  <div class="row" id="x" style="display: none;">
    <div class="col-12">
      <span class="d-flex align-items-center purchase-popup">
        <i class="typcn typcn-delete-outline" id="bannerClose"></i>
      </span>
    </div>
  </div>
  <div class="container-scroller">
    @include('layout.navbar')
    <!-- partial -->
    @include('layout.breadscrum')
    <div class="container-fluid page-body-wrapper">

      @include('layout.sidebar')

      <!-- partial -->
      <div class="main-panel">
        <div class="content-wrapper">
          <div class="row">
            <div class="col-md-12 grid-margin stretch-card">
                <div class="card">
                    <div class="card-body">
                        <h4 class="card-title"><i class="mdi mdi-dots-vertical menu-icon"></i> Patient Register</h4>
                        <div class="row">
                            <div class="col-md-4">
                                <div class="form-group row">
                                    <label for="patient_name" class="col-sm-5 col-form-label">Patient Name</label>
                                    <input type="text" class="form-control form-control-sm col-sm-7" id="patient_name" placeholder="Patient name">

                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group row">
                                    <label for="patient_id" class="col-sm-5 col-form-label">Patient ID</label>
                                    <input type="text" class="form-control form-control-sm col-sm-7" id="patient_id" placeholder="Patient ID">
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group row">
                                    <label for="phonenumer" class="col-sm-5 col-form-label">Phone number</label>
                                    <input type="text" class="form-control form-control-sm col-sm-7" id="patient_id" placeholder="Phone number">
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group row">
                                    <label for="gender" class="col-sm-5 col-form-label">Gender</label>
                                    <select class="form-control form-control-sm col-sm-7" id="exampleFormControlSelect3">
                                        <option>Select</option>
                                        <option>Female</option>
                                        <option>Male</option>
                                      </select>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group row">
                                    <label for="exampleInputUsername2" class="col-sm-5 col-form-label">Request Date:</label>
                                    <input type="text" class="form-control form-control-sm col-sm-7" id="request_date" placeholder="">

                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group row">
                                    <label for="exampleInputUsername2" class="col-sm-5 col-form-label">Address</label>
                                    <select class="form-control form-control-sm col-sm-7" id="exampleFormControlSelect3">
                                        <option>Phnom Penh</option>
                                        <option>Takeo</option>
                                    </select>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>

            <div class="col-md-12 grid-margin stretch-card">
                <div class="card">
                    <div class="card-body">
                        <h4 class="card-title">Sample Information</h4>
                        <div class="row">
                            <div class="col-md-9">
                                <div class="row">
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="gender" class="col-sm-5 col-form-label">Requester Name</label>
                                            <select class="form-control form-control-sm col-sm-7" id="requester_name">
                                                <option>Dr. A</option>
                                                <option>Dr. B</option>
                                              </select>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="labid" class="col-sm-5 col-form-label">Lab ID</label>
                                            <input type="text" class="form-control form-control-sm col-sm-7" id="lab_id" placeholder="Sample number">
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="labid" class="col-sm-5 col-form-label">Request Date/Time</label>
                                            <input type="text" class="form-control form-control-sm col-sm-7" id="request_date_time" placeholder="">
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="received_date_time" class="col-sm-5 col-form-label">Receive Date/Time</label>
                                            <input type="text" class="form-control form-control-sm col-sm-7" id="received_date_time" placeholder="">
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="sample_source" class="col-sm-5 col-form-label">Sample Source</label>
                                            <select class="form-control form-control-sm col-sm-7" id="sample_source">
                                                <option>ODP</option>
                                                <option>ICU</option>
                                              </select>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="diagnosis" class="col-sm-5 col-form-label">Diagnosis</label>
                                            <select class="form-control form-control-sm col-sm-7" id="diagnosis">
                                                <option>A1</option>
                                                <option>None</option>
                                            </select>
                                        </div>
                                    </div>

                                    <div class="col-md-2">
                                        <div class="form-check form-check-primary">
                                            <label class="form-check-label">
                                              <input type="checkbox" class="form-check-input" checked="">
                                              Urgent
                                            <i class="input-helper"></i></label>
                                          </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group row">
                                            <label for="sample_condition" class="col-sm-5 col-form-label">Sample condition</label>
                                            <select class="form-control form-control-sm col-sm-7" id="sample_condition">
                                                <option>Good</option>
                                                <option>Acceptable</option>
                                                <option>Rejected</option>
                                              </select>
                                        </div>
                                    </div>
                                    <div class="col-md-4">
                                        <div class="form-group row">
                                            <label for="diagnosis" class="col-sm-5 col-form-label">Rejection    </label>
                                            <select class="form-control form-control-sm col-sm-7" id="rejected_reason">
                                                <option>Reason 1</option>
                                                <option>Reason 2</option>
                                            </select>
                                        </div>
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-3">
                                <button type="button" class="btn btn-info btn-icon-text btn-lg btn-block">
                                    <i class="typcn typcn-document btn-icon-prepend"></i>
                                    Assign Test
                                </button>
                                <button type="button" class="btn btn-danger btn-icon-text btn-lg btn-block">
                                    <i class="typcn typcn-document btn-icon-prepend"></i>
                                    Add Result
                                </button>
                                <button type="button" class="btn btn-info btn-icon-text btn-lg btn-block">
                                    <i class="typcn typcn-warning btn-icon-prepend"></i>
                                    Delete Sample
                                </button>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
          </div>
        </div>
        @include('layout.footer')
      </div>
    </div>
  </div>
  @include('layout.common_script')
  <!-- plugin js for this page -->
  <script src="{{url(env("APP_URL").'storage/assets/vendors/typeahead.js/typeahead.bundle.min.js')}}"></script>
  <script src="{{url(env("APP_URL").'storage/assets/vendors/select2/select2.min.js')}}"></script>
  <script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/1.12.4/jquery.min.js"></script>
  <script src="https://cdnjs.cloudflare.com/ajax/libs/moment.js/2.15.1/moment.min.js"></script>
  <script src="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/3.3.7/js/bootstrap.min.js"></script>
  <script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datetimepicker/4.7.14/js/bootstrap-datetimepicker.min.js"></script>
  <script type="text/javascript">
    $(function() {
        $('#datetimepicker').datetimepicker();
    });
  </script>
</body>

</html>

