interface/new/new.php

   1 <?php
   2 include_once("../globals.php");
   3 ?>
   4 <html>
   5
   6 <head>
   7 <?php html_header_show();?>
   8 <link rel="stylesheet" href="<?php echo xl($css_header,'e');?>" type="text/css">
   9
  10 <script LANGUAGE="JavaScript">
  11
  12  function validate() {
  13 <?php if ($GLOBALS['inhouse_pharmacy']) { ?>
  14   var f = document.forms[0];
  15   if (f.refsource.selectedIndex <= 0) {
  16    alert('Please select a referral source!');
  17    return false;
  18   }
  19 <?php } ?>
  20   top.restoreSession();
  21   return true;
  22  }
  23
  24 </script>
  25
  26 </head>
  27
  28 <body class="body_top" onload="javascript:document.new_patient.fname.focus();">
  29
  30 <?php if ($GLOBALS['concurrent_layout']) { ?>
  31 <form name='new_patient' method='post' action="new_patient_save.php"
  32  onsubmit='return validate()'>
  33 <span class='title'><?php xl('New Patient','e');?></span>
  34 <?php } else { ?>
  35 <form name='new_patient' method='post' action="new_patient_save.php"
  36  target='_top' onsubmit='return validate()'>
  37 <a class="title" href="../main/main_screen.php" target="_top" onclick="top.restoreSession()">
  38 <?php xl('New Patient','e');?></a>
  39 <?php } ?>
  40
  41 <br><br>
  42
  43 <center>
  44
  45 <?php if ($GLOBALS['omit_employers']) { ?>
  46    <input type='hidden' name='title' value='' />
  47 <?php } ?>
  48
  49 <table border='0'>
  50
  51 <?php if (!$GLOBALS['omit_employers']) { ?>
  52  <tr>
  53   <td>
  54    <span class='bold'><?php xl('Title','e');?>: </span>
  55   </td>
  56   <td>
  57    <select name='title'>
  58     <option value="Mrs."><?php xl('Mrs.','e');?></option>
  59     <option value="Ms."><?php xl('Ms.','e');?></option>
  60     <option value="Mr."><?php xl('Mr.','e');?></option>
  61     <option value="Dr."><?php xl('Dr.','e');?></option>
  62    </select>
  63   </td>
  64  </tr>
  65 <?php } ?>
  66
  67  <tr>
  68   <td>
  69    <span class='bold'><?php xl('First Name','e');?>: </span>
  70   </td>
  71   <td>
  72    <input type='entry' size='15' name='fname'>
  73   </td>
  74  </tr>
  75
  76  <tr>
  77   <td>
  78    <span class='bold'><?php xl('Middle Name','e');?>: </span>
  79   </td>
  80   <td>
  81    <input type='entry' size='15' name='mname'>
  82   </td>
  83  </tr>
  84
  85  <tr>
  86   <td>
  87    <span class='bold'><?php xl('Last Name','e');?>: </span>
  88   </td>
  89   <td>
  90    <input type='entry' size='15' name='lname'>
  91   </td>
  92  </tr>
  93
  94 <?php if ($GLOBALS['inhouse_pharmacy']) { ?>
  95  <tr>
  96   <td>
  97    <span class='bold'><?php xl('Referral Source','e'); ?>: </span>
  98   </td>
  99   <td>
 100    <select name='refsource'>
 101 <?php
 102  foreach (array('', 'Patient', 'Employee', 'Walk-In', 'Newspaper', 'Radio',
 103   'T.V.', 'Direct Mail', 'Coupon', 'Referral Card', 'Other') as $rs)
 104  {
 105   echo "    <option value='$rs'>$rs</option>\n";
 106  }
 107 ?>
 108    </select>
 109   </td>
 110  </tr>
 111 <?php } ?>
 112
 113  <tr>
 114   <td>
 115    <span class='bold'><?php xl('Patient Number','e');?>: </span>
 116   </td>
 117   <td>
 118    <input type='entry' size='5' name='pubpid'>
 119    <span class='text'><?php xl('omit to autoassign','e');?> &nbsp; &nbsp; </span>
 120   </td>
 121  </tr>
 122
 123  <tr>
 124   <td colspan='2'>
 125    &nbsp;<br>
 126    <input type='submit' name='form_create' value=<?php xl('Create New Patient','e'); ?> />
 127   </td>
 128   <td>
 129   </td>
 130  </tr>
 131
 132 </table>
 133 </center>
 134 </form>
 135
 136 </body>
 137 </html>