interface/new/new.php

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