streamline-emr/docker/_streamline-src/resources/views/hospital_information/create.blade.php

@extends('layouts.main')

@push('styles')
    <link href="{{ asset('elite/bower_components/bootstrap-datepicker/bootstrap-datepicker.min.css') }}" rel="stylesheet" type="text/css" />
    <link href="{{ asset('elite/bower_components/select2/select2.min.css') }}" rel="stylesheet" />
@endpush

@section('content')
<div class="row bg-title">
    <div class="col-lg-3 col-md-4 col-sm-4 col-xs-12">
        <h4 class="page-title">{{ __('hospital_information.hospital_information') }}</h4>
    </div>
    <div class="col-lg-9 col-sm-8 col-md-8 col-xs-12">
        <ol class="breadcrumb">
            <li><a href="{{ route('home') }}">{{ __('hospital_information.dashboard') }}</a></li>
            <li><a href="/hospital_information/edit">{{ __('hospital_information.hospital_information') }}</a></li>
            <li class="active">{{ __('hospital_information.edit') }}</li>
        </ol>
    </div>
</div>

<div class="row">
    <div class="col-sm-12">
        <!--Flash messages at the top -->
        @include('flash::message')
        <div class="white-box">
            @if (session()->has('streamline_setup'))
                <h3><font color="blue">Stre@mline {{ __('hospital_information.setup') }} ({{ __('hospital_information.step') }} 1 {{ __('hospital_information.of') }} 10)</font></h3>
            @endif

            {{ Form::open(['route' => 'hospital_information.store', 'data-toggle' => 'validator', 'files' => true]) }}

            <div class="row">
                <div class="col-md-6">
                    <div class="form-group">
                        {{ Form::label('name', __('hospital_information.hospital_name')) }}
                        {{ Form::text('name', '', ['class' => 'form-control compulsory', 'required', 'data-error'=>'']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('level', __('hospital_information.level')) }}
                        {{ Form::text('level', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('code', __('hospital_information.code')) }}
                        {{ Form::text('code', '', ['class' => 'form-control']) }}
                    </div>

                    <div class="form-group">
                        {{ Form::label('parish', __('hospital_information.parish')) }}
                        {{ Form::select('parish', $parishes, '', ['class' => 'form-control parish']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('sub_county', __('hospital_information.sub_county')) }}
                        {{ Form::select('sub_county', $subcounties, '', ['class' => 'form-control sub_county']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('sub_district', __('hospital_information.health_sub_district')) }}
                        {{ Form::text('sub_district', '', ['class' => 'form-control sub_district']) }}
                    </div>

                    <div class="form-group">
                        {{ Form::label('address', __('hospital_information.address')) }}
                        {{ Form::text('address', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('website', __('hospital_information.website')) }}
                        {{ Form::text('website', '', ['class' => 'form-control']) }}
                    </div>
                </div>

                <div class="col-md-6">
                    <div class="form-group">
                        {{ Form::label('phone_number', __('hospital_information.phone_number')) }}
                        {{ Form::text('phone_number', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('email', __('hospital_information.email')) }}
                        {{ Form::email('email', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('financial_year_start_date', 'Start of Financial Year') }}
                        {{-- {{ Form::date('financial_year_start_date', '', ['class' => 'form-control', 'required']) }} --}}
                        <select id="month" name="financial_year_start_date" class = "form-control compulsory">
                            <option value="">-- Select --</option>
                            <option value="01">January</option>
                            <option value="02">February</option>
                            <option value="03">March</option>
                            <option value="04">April</option>
                            <option value="05">May</option>
                            <option value="06">June</option>
                            <option value="07">July</option>
                            <option value="08">August</option>
                            <option value="09">September</option>
                            <option value="10">October</option>
                            <option value="11">November</option>
                            <option value="12">December</option>
                        </select>
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('back_date', 'Back Dating Cutoff Days') }}
                        {{ Form::number('back_date', '', ['class' => 'form-control compulsory', 'required','min' => 1]) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('district', __('hospital_information.district')) }}
                        {{ Form::select('district', $districts, '', ['class' => 'form-control compulsory district']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('country', __('hospital_information.country')) }}
                        {{ Form::text('country', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    {{--<div class="form-group">
                        {{ Form::label('app_name', 'App name') }}
                        {{ Form::text('app_name', '', ['class' => 'form-control compulsory', 'required']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('app_version', 'App version') }}
                        {{ Form::number('app_version', '', ['class' => 'form-control compulsory', 'required', 'step' => 0.1]) }}
                        <div class="help-block with-errors"></div>
                    </div>--}}

                    <div class="form-group">
                        {{ Form::label('patient_number_abbr', __('hospital_information.patient_number_abbr')) }}
                        {{ Form::text('patient_number_abbr', '', ['class' => 'form-control compulsory', 'required', 'max'=>'3']) }}
                        <div class="help-block with-errors"></div>
                    </div>

                    <div class="form-group">
                        {{ Form::label('logo', __('hospital_information.system_logo')) }}
                        {{ Form::file('logo', null) }}
                        {{ Form::text('current_logo', '', ['class' => 'form-control', 'hidden']) }}
                    </div>
                    <div class="form-group">
                        {{ Form::label('stamp', __('hospital_information.stamp')) }}
                        {{ Form::file('stamp', null) }}
                        {{ Form::text('current_stamp', '', ['class' => 'form-control', 'hidden']) }}
                    </div>
                    <div class="form-group">
                        {{ Form::label('lab_stamp', __('hospital_information.lab_stamp')) }}
                        {{ Form::file('lab_stamp', null) }}
                        {{ Form::text('current_lab_stamp', '', ['class' => 'form-control', 'hidden']) }}
                    </div>
                </div>
            </div>

            {{ Form::button(__('hospital_information.next'),['type'=>'submit','class'=>'btn btn-success btn-lg waves-effect waves-light m-r-10']) }}
            {{--{{ Form::button('Skip',['type'=>'reset','class'=>'btn btn-default btn-lg waves-effect waves-light']) }}--}}

            {{ Form::close() }}
        </div>
    </div>
</div>
@endsection

@push('scripts')
<script src="{{ asset('elite/js/validator.js') }}"></script>
<script src="{{ asset('elite/bower_components/select2/select2.min.js') }}"></script>
<script type="text/javascript">
    $(document).ready(function(){
        $('.parish,.sub_county,.district').select2({
            placeholder: "-- select --"
        });

        $('.select2-selection.select2-selection--single').css('height','calc(3.85rem)');
        $('.select2-selection.select2-selection--single').css('padding-top','5px');
        //$('.select2-selection.select2-selection--single').css('border-left', '3px solid #F08080');/*add compulsory class*/
        $('.select2-selection.select2-selection--single.sec_d').css('border-left', '3px solid #aaa');
        $('.select2-selection__arrow').css('top','3px');
    })
</script>
@endpush