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   return true;
  20  }
  21
  22 </script>
  23
  24 </head>
  25
  26 <body <?php echo $top_bg_line;?> topmargin='0' rightmargin='0' leftmargin='2'
  27  bottommargin='0' marginwidth='2' marginheight='0'
  28  onload="javascript:document.new_patient.fname.focus();">
  29
  30 <?php if ($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"><?php xl('New Patient','e');?></a>
  38 <?php } ?>
  39
  40 <br><br>
  41
  42 <center>
  43
  44 <?php if ($GLOBALS['omit_employers']) { ?>
  45    <input type='hidden' name='title' value='' />
  46 <?php } ?>
  47
  48 <table border='0'>
  49
  50 <?php if (!$GLOBALS['omit_employers']) { ?>
  51  <tr>
  52   <td>
  53    <span class='bold'><?php xl('Title','e');?>: </span>
  54   </td>
  55   <td>
  56    <select name='title'>
  57     <option value="Mrs."><?php xl('Mrs.','e');?></option>
  58     <option value="Ms."><?php xl('Ms.','e');?></option>
  59     <option value="Mr."><?php xl('Mr.','e');?></option>
  60     <option value="Dr."><?php xl('Dr.','e');?></option>
  61    </select>
  62   </td>
  63  </tr>
  64 <?php } ?>
  65
  66  <tr>
  67   <td>
  68    <span class='bold'><?php xl('First Name','e');?>: </span>
  69   </td>
  70   <td>
  71    <input type='entry' size='15' name='fname'>
  72   </td>
  73  </tr>
  74
  75  <tr>
  76   <td>
  77    <span class='bold'><?php xl('Middle Name','e');?>: </span>
  78   </td>
  79   <td>
  80    <input type='entry' size='15' name='mname'>
  81   </td>
  82  </tr>
  83
  84  <tr>
  85   <td>
  86    <span class='bold'><?php xl('Last Name','e');?>: </span>
  87   </td>
  88   <td>
  89    <input type='entry' size='15' name='lname'>
  90   </td>
  91  </tr>
  92
  93 <?php if ($GLOBALS['inhouse_pharmacy']) { ?>
  94  <tr>
  95   <td>
  96    <span class='bold'><?php xl('Referral Source','e'); ?>: </span>
  97   </td>
  98   <td>
  99    <select name='refsource'>
 100 <?php
 101  foreach (array('', 'Patient', 'Employee', 'Walk-In', 'Newspaper', 'Radio',
 102   'T.V.', 'Direct Mail', 'Coupon', 'Referral Card', 'Other') as $rs)
 103  {
 104   echo "    <option value='$rs'>$rs</option>\n";
 105  }
 106 ?>
 107    </select>
 108   </td>
 109  </tr>
 110 <?php } ?>
 111
 112  <tr>
 113   <td>
 114    <span class='bold'><?php xl('Patient Number','e');?>: </span>
 115   </td>
 116   <td>
 117    <input type='entry' size='5' name='pubpid'>
 118    <span class='text'><?php xl('omit to autoassign','e');?> &nbsp; &nbsp; </span>
 119   </td>
 120  </tr>
 121
 122  <tr>
 123   <td colspan='2'>
 124    &nbsp;<br>
 125    <input type='submit' name='form_create' value=<?php xl('Create New Patient','e'); ?> />
 126   </td>
 127   <td>
 128   </td>
 129  </tr>
 130
 131 </table>
 132 </center>
 133 </form>
 134
 135 </body>
 136 </html>