205 lines
12 KiB
PHP
205 lines
12 KiB
PHP
<!DOCTYPE html>
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<html lang="{{ str_replace('_', '-', app()->getLocale()) }}">
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<head>
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@include('layout.header')
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<link rel="stylesheet" href="{{ asset('assets/vendors/select2/select2.min.css') }}">
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</head>
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<body>
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<div class="row" id="x" style="display: none;">
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<div class="col-12">
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<span class="d-flex align-items-center purchase-popup">
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<i class="typcn typcn-delete-outline" id="bannerClose"></i>
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</span>
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</div>
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</div>
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<div class="container-scroller">
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@include('layout.navbar')
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<!-- partial -->
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@include('layout.breadscrum')
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<div class="container-fluid page-body-wrapper">
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@include('layout.sidebar')
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<!-- partial -->
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<div class="main-panel">
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<div class="content-wrapper">
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<div class="row">
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<div class="col-md-12 grid-margin stretch-card">
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<div class="card">
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<div class="card-body">
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<h4 class="card-title"><i class="mdi mdi-dots-vertical menu-icon"></i> Patient Register</h4>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group row">
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<label for="patient_name" class="col-sm-5 col-form-label">Patient Name</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="patient_name" placeholder="Patient name">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group row">
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<label for="patient_id" class="col-sm-5 col-form-label">Patient ID</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="patient_id" placeholder="Patient ID">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group row">
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<label for="phonenumer" class="col-sm-5 col-form-label">Phone number</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="patient_id" placeholder="Phone number">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group row">
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<label for="gender" class="col-sm-5 col-form-label">Gender</label>
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<select class="form-control form-control-sm col-sm-7" id="exampleFormControlSelect3">
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<option>Select</option>
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<option>Female</option>
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<option>Male</option>
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</select>
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group row">
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<label for="exampleInputUsername2" class="col-sm-5 col-form-label">Request Date:</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="request_date" placeholder="">
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group row">
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<label for="exampleInputUsername2" class="col-sm-5 col-form-label">Address</label>
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<select class="form-control form-control-sm col-sm-7" id="exampleFormControlSelect3">
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<option>Phnom Penh</option>
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<option>Takeo</option>
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</select>
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</div>
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</div>
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</div>
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</div>
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</div>
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</div>
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<div class="col-md-12 grid-margin stretch-card">
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<div class="card">
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<div class="card-body">
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<h4 class="card-title">Sample Information</h4>
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<div class="row">
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<div class="col-md-9">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group row">
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<label for="gender" class="col-sm-5 col-form-label">Requester Name</label>
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<select class="form-control form-control-sm col-sm-7" id="requester_name">
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<option>Dr. A</option>
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<option>Dr. B</option>
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</select>
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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 row">
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<label for="labid" class="col-sm-5 col-form-label">Lab ID</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="lab_id" placeholder="Sample number">
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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 row">
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<label for="labid" class="col-sm-5 col-form-label">Request Date/Time</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="request_date_time" placeholder="">
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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 row">
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<label for="received_date_time" class="col-sm-5 col-form-label">Receive Date/Time</label>
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<input type="text" class="form-control form-control-sm col-sm-7" id="received_date_time" placeholder="">
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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 row">
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<label for="sample_source" class="col-sm-5 col-form-label">Sample Source</label>
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<select class="form-control form-control-sm col-sm-7" id="sample_source">
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<option>ODP</option>
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<option>ICU</option>
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</select>
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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 row">
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<label for="diagnosis" class="col-sm-5 col-form-label">Diagnosis</label>
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<select class="form-control form-control-sm col-sm-7" id="diagnosis">
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<option>A1</option>
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<option>None</option>
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</select>
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</div>
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</div>
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<div class="col-md-2">
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<div class="form-check form-check-primary">
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<label class="form-check-label">
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<input type="checkbox" class="form-check-input" checked="">
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Urgent
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<i class="input-helper"></i></label>
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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 row">
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<label for="sample_condition" class="col-sm-5 col-form-label">Sample condition</label>
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<select class="form-control form-control-sm col-sm-7" id="sample_condition">
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<option>Good</option>
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<option>Acceptable</option>
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<option>Rejected</option>
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</select>
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group row">
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<label for="diagnosis" class="col-sm-5 col-form-label">Rejection </label>
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<select class="form-control form-control-sm col-sm-7" id="rejected_reason">
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<option>Reason 1</option>
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<option>Reason 2</option>
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</select>
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</div>
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</div>
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</div>
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</div>
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<div class="col-md-3">
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<button type="button" class="btn btn-info btn-icon-text btn-lg btn-block">
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<i class="typcn typcn-document btn-icon-prepend"></i>
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Assign Test
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</button>
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<button type="button" class="btn btn-danger btn-icon-text btn-lg btn-block">
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<i class="typcn typcn-document btn-icon-prepend"></i>
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Add Result
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</button>
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<button type="button" class="btn btn-info btn-icon-text btn-lg btn-block">
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<i class="typcn typcn-warning btn-icon-prepend"></i>
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Delete Sample
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</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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</div>
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</div>
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</div>
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@include('layout.footer')
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</div>
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</div>
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</div>
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@include('layout.common_script')
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<!-- plugin js for this page -->
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<script src="{{url(env("APP_URL").'storage/assets/vendors/typeahead.js/typeahead.bundle.min.js')}}"></script>
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<script src="{{url(env("APP_URL").'storage/assets/vendors/select2/select2.min.js')}}"></script>
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<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/1.12.4/jquery.min.js"></script>
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<script src="https://cdnjs.cloudflare.com/ajax/libs/moment.js/2.15.1/moment.min.js"></script>
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<script src="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/3.3.7/js/bootstrap.min.js"></script>
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<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-datetimepicker/4.7.14/js/bootstrap-datetimepicker.min.js"></script>
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<script type="text/javascript">
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$(function() {
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$('#datetimepicker').datetimepicker();
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});
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</script>
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</body>
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</html>
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