mirror of
https://gitlab.com/signalytic/client-external/streamline/streamline-emr.git
synced 2026-09-12 11:11:31 +00:00
resolved conflicts
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@extends('layouts.main')
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@push('styles')
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<link href="{{ asset('elite/bower_components/select2/select2.min.css') }}" rel="stylesheet" />
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<link href="{{ asset('elite/bower_components/bootstrap-datepicker/bootstrap-datepicker.min.css') }}" rel="stylesheet" type="text/css" />
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@endpush
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@section('content')
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<div class="row bg-title">
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<div class="col-lg-3 col-md-4 col-sm-4 col-xs-12">
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<h4 class="page-title">{{ __('insurance_groups.new_insurance_group') }}</h4>
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</div>
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<div class="col-lg-9 col-sm-8 col-md-8 col-xs-12">
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<ol class="breadcrumb">
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<li><a href="{{ route('home') }}">{{ __('insurance_groups.dashboard') }}</a></li>
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<li><a href="/insurance/scheme_administration">{{ __('insurance.scheme_administration') }}</a></li>
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<li><a href="/insurance_groups/">{{ __('insurance_groups.insurance_groups') }}</a></li>
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<li class="active">{{ __('insurance_groups.register') }}</li>
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</ol>
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</div>
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</div>
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@include('insurance::insurance_groups.menu')
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@include('flash::message')
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@include ('errors.list')
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<div class="panel panel-default">
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<div class="panel-body">
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{{ Form::open(['route' => 'insurance_groups.store','data-toggle'=>'validator']) }}
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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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{{ Form::label('name', __('insurance_groups.group_name')) }}
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{{ Form::text('name', '', ['class' => 'form-control compulsory', 'required']) }}
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('contact_name', __('insurance_groups.contact_name')) }}
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{{ Form::text('contact_name', '', ['class' => 'form-control compulsory', 'required']) }}
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('contact_number',__('insurance_groups.contact_phone_number')) }}
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{{ Form::text('contact_number','',['class' => 'form-control compulsory','required']) }}
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('group_email',__('insurance.email')) }}
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{{ Form::email('group_email','',['class' => 'form-control compulsory']) }}
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<div class="help-block with-errors"></div>
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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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{{ Form::label('country_id',__('patients.country_of_origin')) }}
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{{ Form::select('country_id', $countries, '',['class' => 'form-control', 'data-error'=>'Select the country', 'required']) }}
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('last_fees_billing_date', __('insurance.date_of_last_fees_billing')) }}
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<div class="input-group">
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{{ Form::text('last_fees_billing_date','',['class' => 'form-control','readonly','id'=>'last_fees_billing_date']) }}
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<span class="input-group-addon"><i class="icon-calender"></i></span>
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</div>
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('last_fees_payment_date', __('insurance.date_of_last_fees_payment')) }}
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<div class="input-group">
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{{ Form::text('last_fees_payment_date','',['class' => 'form-control','readonly','id'=>'last_fees_payment_date']) }}
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<span class="input-group-addon"><i class="icon-calender"></i></span>
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</div>
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('risk_id',__('insurance.risk')) }}
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{{ Form::select('risk_id[]', $chi_risks, '',['class' => 'form-control compulsory risk_id', 'data-error'=>'Select the risk', 'required', 'multiple']) }}
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<div class="help-block with-errors"></div>
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</div>
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</div>
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</div>
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{{ Form::button(__('insurance_groups.submit'),['type'=>'submit','class'=>'btn btn-success waves-effect waves-light m-r-10']) }}
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{{ Form::button(__('insurance_groups.cancel'),['type'=>'reset','class'=>'btn btn-default waves-effect waves-light']) }}
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{{ Form::close() }}
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</div>
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</div>
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@endsection
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@push('scripts')
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<script src="{{ asset('elite/js/validator.js') }}"></script>
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<script src="{{ asset('elite/js/mask.js') }}"></script>
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<script src="{{ asset('elite/bower_components/bootstrap-datepicker/bootstrap-datepicker.min.js') }}"></script>
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<script src="{{ asset('elite/bower_components/select2/select2.min.js') }}"></script>
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<script type="text/javascript">
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$('.risk_id').select2({
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placeholder: "Select"
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});
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$('#last_fees_billing_date,#last_fees_payment_date').datepicker({
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autoclose: true,
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todayHighlight: true,
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format: 'dd-mm-yyyy'
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});
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</script>
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@endpush
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