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https://gitlab.com/signalytic/client-external/streamline/streamline-emr.git
synced 2026-09-12 03:01:32 +00:00
updated streamline-setup v2
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@extends('layouts.main')
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@push('styles')
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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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<link href="{{ asset('elite/bower_components/select2/select2.min.css') }}" rel="stylesheet"/>
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@endpush
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@section('title', '| Edit Plan')
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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.create_chi_plan') }}</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="{{ url('insurance') }}">{{ __('insurance.home') }}</a></li>
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<li><a href="{{ route('community_health_insurance_plan.index') }}">{{ __('insurance.chi_plan') }}</a></li>
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<li class="active">{{ __('insurance.create_chi_plan') }}</li>
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</ol>
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</div>
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<!-- /.col-lg-12 -->
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</div>
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<div class="row">
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<div class="col-sm-12">
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@include('insurance::chi_plan.menu')
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</div>
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</div>
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@include('flash::message')
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<div class="panel panel-default" style="border-radius: 5px;">
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<div class="panel-body">
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{{ Form::model($chi_plan, ['method' => 'PUT', 'route' => ['community_health_insurance_plan.update',$chi_plan]]) }}
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<div class="row">
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<div class="col-sm-6">
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<div class="form-group">
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{{ Form::label('name', __('insurance.name')) }}
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{{ Form::text('name', $chi_plan->name, ['class' => 'form-control compulsory', 'required']) }}
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<div class="help-block with-errors"></div>
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</div>
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<div class="form-group">
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{{ Form::label('plan_start_date', __('insurance.start_date')) }}
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<div class="input-group">
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{{ Form::text('plan_start_date',date_format(date_create($chi_plan->plan_start_date), 'd-m-Y'),['class' => 'form-control compulsory','readonly','id'=>'plan_start_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('plan_end_date', __('insurance.end_date')) }}
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<div class="input-group">
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{{ Form::text('plan_end_date',date_format(date_create($chi_plan->plan_end_date), 'd-m-Y'),['class' => 'form-control compulsory','readonly','id'=>'plan_end_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('is_authorization_required', __('insurance.is_authorization_required')) }}
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{{ Form::select('is_authorization_required', ['' => '-- Select --', 1 => 'Yes', 0 => 'No'], $chi_plan->is_authorized_required, ['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>
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<div class="col-sm-6">
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<div class="form-group">
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{{ Form::label('plan_fee', __('insurance.plan_fee')) }}
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{{ Form::number('plan_fee', $chi_plan->plan_fee, ['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('member_annual_limit', __('insurance.overall_annual_limit_for_member') . ' (' . __('insurance_claims.no_limit_applicable') . ')') }}
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{{ Form::number('member_annual_limit', $chi_plan->member_annual_limit, ['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('family_annual_limit', __('insurance.overall_annual_limit_for_family') . ' (' . __('insurance_claims.no_limit_applicable') . ')') }}
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{{ Form::number('family_annual_limit', $chi_plan->family_annual_limit, ['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('membership_card_color', __('insurance.membership_card_color')) }}
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{{ Form::select('membership_card_color', ['' => '-- Select --', 'green' => 'Green', 'blue' => 'Blue'], $chi_plan->membership_card_color, ['class' => 'form-control compulsory', 'required']) }}
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<div class="help-block with-errors"></div>
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</div>
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</div>
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</div>
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{{ Form::button(__('drug_forms.submit'),['type'=>'submit','class'=>'btn btn-success btn-rounded waves-effect waves-light m-r-10']) }}
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{{ Form::button(__('drug_forms.cancel'),['type'=>'reset','class'=>'btn btn-default btn-rounded waves-effect waves-light']) }}
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{{ Form::close() }}
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</div>
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</div>
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@endsection
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@push('scripts')
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<script src="{{ asset('elite/js/validator.js') }}"></script>
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<script src="{{ asset('elite/bower_components/select2/select2.min.js') }}"></script>
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<script src="{{ asset('elite/bower_components/bootstrap-datepicker/bootstrap-datepicker.min.js') }}"></script>
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<script type="text/javascript">
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$('#plan_start_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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$('#plan_end_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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