interface/new/new.php

   1 <?
   2 include_once("../globals.php");
   3
   4
   5
   6 ?>
   7
   8
   9 <html>
  10 <head>
  11
  12
  13 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  14
  15 </head>
  16 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0 onload="javascript:document.new_patient.fname.focus();">
  17
  18 <form name=new_patient method=post action="new_patient_save.php" target=_top>
  19 <a class="title" href="../main/main_screen.php" target="_top">New Patient</a>
  20
  21 <br><br>
  22
  23 <table border=0>
  24 <tr>
  25 <td>
  26 <span class=bold>Title: </span></td><td>
  27 <select name=title>
  28         <option value="Mr.">Mr.</option>
  29         <option value="Mrs.">Mrs.</option>
  30         <option value="Ms.">Ms.</option>
  31         <option value="Dr.">Dr.</option>
  32 </select>
  33 </td>
  34 </tr>
  35
  36 <tr>
  37 <td>
  38 <span class=bold>First Name: </span></td><td>
  39 <input type=entry size=15 name=fname>
  40 </td></tr>
  41
  42 <tr>
  43 <td>
  44 <span class=bold>Middle Name: </span></td><td>
  45 <input type=entry size=15 name=mname>
  46 </td></tr>
  47
  48 <tr>
  49 <td>
  50 <span class=bold>Last Name: </span></td><td>
  51 <input type=entry size=15 name=lname>
  52 </td></tr>
  53
  54 <tr>
  55 <td>
  56 <span class=bold>Patient Number: </span></td><td>
  57 <input type=entry size=5 name=pubpid>
  58 <span class=text>Leave blank to autoassign</span>
  59 </td></tr>
  60
  61 <tr><td colspan=2>
  62 <a href="javascript:document.new_patient.submit();" class=link_submit>[New Patient File]</a>
  63 </td></tr>
  64 </table>
  65 </form>
  66
  67
  68 </body>
  69 </html>