interface/usergroup/addrbook_edit.php

   1 <?php
   2
   3 /**
   4  * addrbook_edit.php
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    Rod Roark <rod@sunsetsystems.com>
   9  * @author    Brady Miller <brady.g.miller@gmail.com>
  10  * @copyright Copyright (c) 2006-2010 Rod Roark <rod@sunsetsystems.com>
  11  * @copyright Copyright (c) 2018-2019 Brady Miller <brady.g.miller@gmail.com>
  12  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  13  */
  14
  15 require_once("../globals.php");
  16 require_once("$srcdir/options.inc.php");
  17
  18 use OpenEMR\Common\Acl\AclMain;
  19 use OpenEMR\Common\Csrf\CsrfUtils;
  20 use OpenEMR\Common\Twig\TwigContainer;
  21 use OpenEMR\Core\Header;
  22
  23 if (!AclMain::aclCheckCore('admin', 'practice')) {
  24     echo (new TwigContainer(null, $GLOBALS['kernel']))->getTwig()->render('core/unauthorized.html.twig', ['pageTitle' => xl("Address Book")]);
  25     exit;
  26 }
  27
  28 if (!empty($_POST)) {
  29     if (!CsrfUtils::verifyCsrfToken($_POST["csrf_token_form"])) {
  30         CsrfUtils::csrfNotVerified();
  31     }
  32 }
  33
  34 // Collect user id if editing entry
  35 $userid = $_REQUEST['userid'] ?? '';
  36
  37 // Collect type if creating a new entry
  38 $type = $_REQUEST['type'] ?? '';
  39
  40 $info_msg = "";
  41
  42 function invalue($name)
  43 {
  44     if (empty($_POST[$name])) {
  45         return "''";
  46     }
  47
  48     $fld = add_escape_custom(trim($_POST[$name]));
  49     return "'$fld'";
  50 }
  51
  52 ?>
  53 <html>
  54 <head>
  55 <title><?php echo $userid ? xlt('Edit Entry') : xlt('Add New Entry') ?></title>
  56
  57     <?php Header::setupHeader('opener'); ?>
  58
  59 <style>
  60 .inputtext {
  61     padding-left: 2px;
  62     padding-right: 2px;
  63 }
  64 </style>
  65
  66 <script>
  67
  68  var type_options_js = Array();
  69     <?php
  70     // Collect the type options. Possible values are:
  71     // 1 = Unassigned (default to person centric)
  72     // 2 = Person Centric
  73     // 3 = Company Centric
  74     $sql = sqlStatement("SELECT option_id, option_value FROM list_options WHERE " .
  75     "list_id = 'abook_type' AND activity = 1");
  76     while ($row_query = sqlFetchArray($sql)) {
  77         echo "type_options_js[" . js_escape($row_query['option_id']) . "]=" . js_escape($row_query['option_value']) . ";\n";
  78     }
  79     ?>
  80
  81  // Process to customize the form by type
  82  function typeSelect(a) {
  83    if(a=='ord_lab'){
  84       $('#cpoe_span').css('display','inline');
  85   } else {
  86        $('#cpoe_span').css('display','none');
  87        $('#form_cpoe').prop('checked', false);
  88   }
  89   if (type_options_js[a] == 3) {
  90    // Company centric:
  91    //   1) Hide the person Name entries
  92    //   2) Hide the Specialty entry
  93    //   3) Show the director Name entries
  94    $(".nameRow").hide();
  95    $(".specialtyRow").hide();
  96    $(".nameDirectorRow").show();
  97   }
  98   else {
  99    // Person centric:
 100    //   1) Hide the director Name entries
 101    //   2) Show the person Name entries
 102    //   3) Show the Specialty entry
 103    $(".nameDirectorRow").hide();
 104    $(".nameRow").show();
 105    $(".specialtyRow").show();
 106   }
 107  }
 108 </script>
 109
 110 </head>
 111
 112 <body class="body_top">
 113 <?php
 114  // If we are saving, then save and close the window.
 115  //
 116 if (!empty($_POST['form_save'])) {
 117  // Collect the form_abook_type option value
 118  //  (ie. patient vs company centric)
 119     $type_sql_row = sqlQuery("SELECT `option_value` FROM `list_options` WHERE `list_id` = 'abook_type' AND `option_id` = ? AND activity = 1", array(trim($_POST['form_abook_type'])));
 120     $option_abook_type = $type_sql_row['option_value'] ?? '';
 121  // Set up any abook_type specific settings
 122     if ($option_abook_type == 3) {
 123         // Company centric
 124         $form_title = invalue('form_director_title');
 125         $form_fname = invalue('form_director_fname');
 126         $form_lname = invalue('form_director_lname');
 127         $form_mname = invalue('form_director_mname');
 128         $form_suffix = invalue('form_director_suffix');
 129     } else {
 130         // Person centric
 131         $form_title = invalue('form_title');
 132         $form_fname = invalue('form_fname');
 133         $form_lname = invalue('form_lname');
 134         $form_mname = invalue('form_mname');
 135         $form_suffix = invalue('form_suffix');
 136     }
 137
 138     if ($userid) {
 139         $query = "UPDATE users SET " .
 140         "abook_type = "   . invalue('form_abook_type')   . ", " .
 141         "title = "        . $form_title                  . ", " .
 142         "fname = "        . $form_fname                  . ", " .
 143         "lname = "        . $form_lname                  . ", " .
 144         "mname = "        . $form_mname                  . ", " .
 145         "suffix = "       . $form_suffix                 . ", " .
 146         "specialty = "    . invalue('form_specialty')    . ", " .
 147         "organization = " . invalue('form_organization') . ", " .
 148         "valedictory = "  . invalue('form_valedictory')  . ", " .
 149         "assistant = "    . invalue('form_assistant')    . ", " .
 150         "federaltaxid = " . invalue('form_federaltaxid') . ", " .
 151         "upin = "         . invalue('form_upin')         . ", " .
 152         "npi = "          . invalue('form_npi')          . ", " .
 153         "taxonomy = "     . invalue('form_taxonomy')     . ", " .
 154         "cpoe = "         . invalue('form_cpoe')         . ", " .
 155         "email = "        . invalue('form_email')        . ", " .
 156         "email_direct = " . invalue('form_email_direct') . ", " .
 157         "url = "          . invalue('form_url')          . ", " .
 158         "street = "       . invalue('form_street')       . ", " .
 159         "streetb = "      . invalue('form_streetb')      . ", " .
 160         "city = "         . invalue('form_city')         . ", " .
 161         "state = "        . invalue('form_state')        . ", " .
 162         "zip = "          . invalue('form_zip')          . ", " .
 163         "street2 = "      . invalue('form_street2')      . ", " .
 164         "streetb2 = "     . invalue('form_streetb2')     . ", " .
 165         "city2 = "        . invalue('form_city2')        . ", " .
 166         "state2 = "       . invalue('form_state2')       . ", " .
 167         "zip2 = "         . invalue('form_zip2')         . ", " .
 168         "phone = "        . invalue('form_phone')        . ", " .
 169         "phonew1 = "      . invalue('form_phonew1')      . ", " .
 170         "phonew2 = "      . invalue('form_phonew2')      . ", " .
 171         "phonecell = "    . invalue('form_phonecell')    . ", " .
 172         "fax = "          . invalue('form_fax')          . ", " .
 173         "notes = "        . invalue('form_notes')        . " "  .
 174         "WHERE id = '" . add_escape_custom($userid) . "'";
 175         sqlStatement($query);
 176     } else {
 177         $userid = sqlInsert("INSERT INTO users ( " .
 178         "username, password, authorized, info, source, " .
 179         "title, fname, lname, mname, suffix, " .
 180         "federaltaxid, federaldrugid, upin, facility, see_auth, active, npi, taxonomy, cpoe, " .
 181         "specialty, organization, valedictory, assistant, billname, email, email_direct, url, " .
 182         "street, streetb, city, state, zip, " .
 183         "street2, streetb2, city2, state2, zip2, " .
 184         "phone, phonew1, phonew2, phonecell, fax, notes, abook_type "            .
 185         ") VALUES ( "                        .
 186         "'', "                               . // username
 187         "'', "                               . // password
 188         "0, "                                . // authorized
 189         "'', "                               . // info
 190         "NULL, "                             . // source
 191         $form_title                   . ", " .
 192         $form_fname                   . ", " .
 193         $form_lname                   . ", " .
 194         $form_mname                   . ", " .
 195         $form_suffix                  . ", " .
 196         invalue('form_federaltaxid')  . ", " .
 197         "'', "                               . // federaldrugid
 198         invalue('form_upin')          . ", " .
 199         "'', "                               . // facility
 200         "0, "                                . // see_auth
 201         "1, "                                . // active
 202         invalue('form_npi')           . ", " .
 203         invalue('form_taxonomy')      . ", " .
 204         invalue('form_cpoe')          . ", " .
 205         invalue('form_specialty')     . ", " .
 206         invalue('form_organization')  . ", " .
 207         invalue('form_valedictory')   . ", " .
 208         invalue('form_assistant')     . ", " .
 209         "'', "                               . // billname
 210         invalue('form_email')         . ", " .
 211         invalue('form_email_direct')  . ", " .
 212         invalue('form_url')           . ", " .
 213         invalue('form_street')        . ", " .
 214         invalue('form_streetb')       . ", " .
 215         invalue('form_city')          . ", " .
 216         invalue('form_state')         . ", " .
 217         invalue('form_zip')           . ", " .
 218         invalue('form_street2')       . ", " .
 219         invalue('form_streetb2')      . ", " .
 220         invalue('form_city2')         . ", " .
 221         invalue('form_state2')        . ", " .
 222         invalue('form_zip2')          . ", " .
 223         invalue('form_phone')         . ", " .
 224         invalue('form_phonew1')       . ", " .
 225         invalue('form_phonew2')       . ", " .
 226         invalue('form_phonecell')     . ", " .
 227         invalue('form_fax')           . ", " .
 228         invalue('form_notes')         . ", " .
 229         invalue('form_abook_type')    . " "  .
 230         ")");
 231     }
 232 } elseif (!empty($_POST['form_delete'])) {
 233     if ($userid) {
 234        // Be careful not to delete internal users.
 235         sqlStatement("DELETE FROM users WHERE id = ? AND username = ''", array($userid));
 236     }
 237 }
 238
 239 if (!empty($_POST['form_save']) || !empty($_POST['form_delete'])) {
 240   // Close this window and redisplay the updated list.
 241     echo "<script>\n";
 242     if ($info_msg) {
 243         echo " alert(" . js_escape($info_msg) . ");\n";
 244     }
 245
 246     echo " window.close();\n";
 247     echo " if (opener.refreshme) opener.refreshme();\n";
 248     echo "</script></body></html>\n";
 249     exit();
 250 }
 251
 252 if ($userid) {
 253     $row = sqlQuery("SELECT * FROM users WHERE id = ?", array($userid));
 254 }
 255
 256 if ($type) { // note this only happens when its new
 257   // Set up type
 258     $row['abook_type'] = $type;
 259 }
 260
 261 ?>
 262
 263 <script>
 264  $(function () {
 265   // customize the form via the type options
 266   typeSelect(<?php echo js_escape($row['abook_type'] ?? null); ?>);
 267   if(typeof abook_type != 'undefined' && abook_type == 'ord_lab') {
 268     $('#cpoe_span').css('display','inline');
 269    }
 270  });
 271 </script>
 272
 273 <form method='post' name='theform' id="theform" action='addrbook_edit.php?userid=<?php echo attr_url($userid) ?>'>
 274 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
 275 <?php if (AclMain::aclCheckCore('admin', 'practice')) { // allow choose type option if have admin access ?>
 276 <div class="form-row">
 277     <div class='col-2'>
 278         <label class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Type'); ?>:</label>
 279     </div>
 280     <div class="col">
 281         <?php echo generate_select_list('form_abook_type', 'abook_type', ($row['abook_type'] ?? null), '', 'Unassigned', 'form-control-sm', 'typeSelect(this.value)'); ?>
 282     </div>
 283 </div>
 284 <?php } // end of if has admin access ?>
 285
 286 <div class="form-row nameRow my-1">
 287     <div class="col-auto">
 288         <label for="title" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Name'); ?>:</label>
 289     </div>
 290     <div class="col-auto">
 291         <?php generate_form_field(array('data_type' => 1,'field_id' => 'title','smallform' => 'true','list_id' => 'titles','empty_title' => ' '), ($row['title'] ?? '')); ?>
 292     </div>
 293     <div class="col-auto">
 294         <label for="form_lname" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Last{{Name}}'); ?>:</label>
 295     </div>
 296     <div class="col-auto">
 297         <input type='text' size='10' name='form_lname' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['lname'] ?? ''); ?>'/>
 298     </div>
 299     <div class="col-auto">
 300         <label for="form_fname" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('First{{Name}}'); ?>:</label>
 301     </div>
 302     <div class="col-auto">
 303         <input type='text' size='10' name='form_fname' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['fname'] ?? ''); ?>' />
 304     </div>
 305     <div class="col-auto">
 306         <label for="form_mname" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Middle{{Name}}'); ?>:</label>
 307     </div>
 308     <div class="col-auto">
 309         <input type='text' size='4' name='form_mname' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['mname'] ?? ''); ?>' />
 310     </div>
 311     <div class="col-auto">
 312         <label for="form_suffix" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Suffix'); ?>:</label>
 313     </div>
 314     <div class="col-auto">
 315         <input type='text' size='4' name='form_suffix' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['suffix'] ?? ''); ?>' />
 316     </div>
 317 </div>
 318
 319 <div class="form-row specialtyRow my-1">
 320     <div class="col-2">
 321         <label for="form_specialty" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Specialty'); ?>:</label>
 322     </div>
 323     <div class="col">
 324         <input type='text' size='40' name='form_specialty' maxlength='250' value='<?php echo attr($row['specialty'] ?? ''); ?>' class='form-control form-control-sm inputtext w-100' />
 325     </div>
 326 </div>
 327
 328 <div class="form-row my-1">
 329     <div class="col-2">
 330         <label for="form_organization" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Organization'); ?>:</label>
 331     </div>
 332     <div class="col">
 333         <input type='text' size='40' name='form_organization' maxlength='250' value='<?php echo attr($row['organization'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 334     <span id='cpoe_span' style="display:none;">
 335         <input type='checkbox' title="<?php echo xla('CPOE'); ?>" name='form_cpoe' id='form_cpoe' value='1' <?php echo (!empty($row['cpoe']) && ($row['cpoe'] == '1')) ? "CHECKED" : ""; ?>/>
 336         <label for='form_cpoe' class="font-weight-bold"><?php echo xlt('CPOE'); ?></label>
 337    </span>
 338     </div>
 339 </div>
 340 <div class="nameDirectorRow">
 341     <label for="director_title" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Director Name'); ?>:</label>
 342     <div class="form-row my-1">
 343         <div class="col-auto">
 344             <?php
 345             generate_form_field(array('data_type' => 1,'field_id' => 'director_title','smallform' => 'true','list_id' => 'titles','empty_title' => ' '), ($row['title'] ?? ''));
 346             ?>
 347         </div>
 348         <div class="col-auto">
 349             <label for="form_director_lname" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Last{{Name}}'); ?>:</label>
 350         </div>
 351         <div class="col-auto">
 352             <input type='text' size='10' name='form_director_lname' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['lname'] ?? ''); ?>'/>
 353         </div>
 354         <div class="col-auto">
 355             <label for="form_director_fname" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('First{{Name}}'); ?>:</label>
 356         </div>
 357         <div class="col-auto">
 358             <input type='text' size='10' name='form_director_fname' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['fname'] ?? ''); ?>' />
 359         </div>
 360         <div class="col-auto">
 361             <label for="form_director_mname" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Middle{{Name}}'); ?>:</label>
 362         </div>
 363         <div class="col-auto">
 364             <input type='text' size='4' name='form_director_mname' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['mname'] ?? ''); ?>' />
 365         </div>
 366         <div class="col-auto">
 367             <label for="form_director_suffix" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Suffix'); ?>:</label>
 368         </div>
 369         <div class="col-auto">
 370             <input type='text' size='4' name='form_director_suffix' class='form-control form-control-sm inputtext' maxlength='50' value='<?php echo attr($row['suffix'] ?? ''); ?>' />
 371         </div>
 372     </div>
 373 </div>
 374
 375 <div class="form-row my-1">
 376     <div class="col-2">
 377         <label for="form_valedictory" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Valedictory'); ?>:</label>
 378     </div>
 379     <div class="col">
 380         <input type='text' size='40' name='form_valedictory' maxlength='250' value='<?php echo attr($row['valedictory'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 381     </div>
 382 </div>
 383
 384 <div class="form-row my-1">
 385     <div class="col-2">
 386         <label for="form_phone" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Home Phone'); ?>:</label>
 387     </div>
 388     <div class="col">
 389         <input type='text' size='11' name='form_phone' value='<?php echo attr($row['phone'] ?? ''); ?>' maxlength='30' class='form-control form-control-sm inputtext' />
 390     </div>
 391     <div class="col-2">
 392         <label for="form_phonecell" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Mobile'); ?>:</label>
 393     </div>
 394     <div class="col">
 395         <input type='text' size='11' name='form_phonecell' maxlength='30' value='<?php echo attr($row['phonecell'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 396     </div>
 397 </div>
 398 <div class="form-row my-1">
 399     <div class="col-2">
 400         <label for="form_phonew1" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Work Phone'); ?>:</label>
 401     </div>
 402     <div class="col">
 403         <input type='text' size='11' name='form_phonew1' value='<?php echo attr($row['phonew1'] ?? ''); ?>' maxlength='30' class='form-control form-control-sm inputtext' />
 404     </div>
 405     <div class="col-1">
 406         <label class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('2nd'); ?>:</label>
 407     </div>
 408     <div class="col">
 409         <input type='text' size='11' name='form_phonew2' value='<?php echo attr($row['phonew2'] ?? ''); ?>' maxlength='30' class='form-control form-control-sm inputtext' />
 410     </div>
 411     <div class="col-1">
 412         <label class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Fax'); ?>:</label>
 413     </div>
 414     <div class="col">
 415         <input type='text' size='11' name='form_fax' value='<?php echo attr($row['fax'] ?? ''); ?>' maxlength='30' class='form-control form-control-sm inputtext' />
 416     </div>
 417 </div>
 418
 419 <div class="form-row my-1">
 420     <div class="col-2">
 421         <label for="form_assistant" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Assistant'); ?>:</label>
 422     </div>
 423     <div class="col-10">
 424         <input type='text' size='40' name='form_assistant' maxlength='250' value='<?php echo attr($row['assistant'] ?? ''); ?>' class='form-control form-control-sm inputtext w-100' />
 425     </div>
 426 </div>
 427
 428 <div class="form-row my-1">
 429     <div class="col-2">
 430         <label for="form_email" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Email'); ?>:</label>
 431     </div>
 432     <div class='col-10'>
 433         <input type='text' size='40' name='form_email' maxlength='250' value='<?php echo attr($row['email'] ?? ''); ?>' class='form-control form-control-sm inputtext w-100' />
 434     </div>
 435 </div>
 436
 437 <div class="form-row my-1">
 438     <div class="col-2">
 439         <label for="form_email_direct" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Trusted Email'); ?>:</label>
 440     </div>
 441     <div class="col-10">
 442         <input type='text' size='40' name='form_email_direct' maxlength='250' value='<?php echo attr($row['email_direct'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 443     </div>
 444 </div>
 445
 446 <div class="form-row my-1">
 447     <div class="col-2">
 448         <label for="form_url" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Website'); ?>:</label>
 449     </div>
 450     <div class="col-10">
 451         <input type='text' size='40' name='form_url' maxlength='250' value='<?php echo attr($row['url'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 452     </div>
 453 </div>
 454
 455 <div class="form-row my-1 align-items-center">
 456     <div class="col-2">
 457         <label for="form_street form_streetb" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Main Address'); ?>:</label>
 458     </div>
 459     <div class="col-10">
 460         <input type='text' size='40' name='form_street' maxlength='60' value='<?php echo attr($row['street'] ?? ''); ?>' class='form-control form-control-sm inputtext mb-1' placeholder="<?php echo xla('Address Line 1'); ?>" />
 461         <input type='text' size='40' name='form_streetb' maxlength='60' value='<?php echo attr($row['streetb'] ?? ''); ?>' class='form-control form-control-sm inputtext mt-1' placeholder="<?php echo xla('Address Line 2'); ?>" />
 462     </div>
 463 </div>
 464
 465 <div class="form-row my-1">
 466     <div class="col-2">
 467         <label for="form_city" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('City'); ?>:</label>
 468     </div>
 469     <div class="col">
 470         <input type='text' size='10' name='form_city' maxlength='30' value='<?php echo attr($row['city'] ?? ''); ?>' class='form-control form-control-sm inputtext' placeholder="<?php echo xla('City'); ?>" />
 471     </div>
 472     <div class="col-2">
 473         <label for="form_state" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('State') . "/" . xlt('county'); ?>:</label>
 474     </div>
 475     <div class="col">
 476         <?php echo generate_select_list('form_state', 'state', ($row['state'] ?? null), '', 'Unassigned', 'form-control-sm', 'typeSelect(this.value)'); ?>
 477     </div>
 478     <div class="col-2">
 479         <label for="form_zip" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Postal code'); ?>:</label>
 480     </div>
 481     <div class="col">
 482         <input type='text' size='10' name='form_zip' maxlength='20' value='<?php echo attr($row['zip'] ?? ''); ?>' class='form-control form-control-sm inputtext' placeholder="<?php echo xla('Postal code'); ?>" />
 483     </div>
 484 </div>
 485
 486 <div class="form-row my-1 align-items-center">
 487     <div class="col-2">
 488         <label for="form_street2 form_streetb2" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Alt Address'); ?>:</label>
 489     </div>
 490     <div class="col-10">
 491         <input type='text' size='40' name='form_street2' maxlength='60' value='<?php echo attr($row['street2'] ?? ''); ?>' class='form-control form-control-sm mb-1 inputtext' placeholder="<?php echo xla('Address Line 1'); ?>" />
 492         <input type='text' size='40' name='form_streetb2' maxlength='60' value='<?php echo attr($row['streetb2'] ?? ''); ?>' class='form-control form-control-sm mt-1 inputtext' placeholder="<?php echo xla('Address Line 2'); ?>" />
 493     </div>
 494 </div>
 495
 496 <div class="form-row my-1">
 497     <div class="col-2">
 498         <label for="form_city2" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Alt City'); ?>:</label>
 499     </div>
 500     <div class="col-auto">
 501         <input type='text' size='10' name='form_city2' maxlength='30' value='<?php echo attr($row['city2'] ?? ''); ?>' class='form-control form-control-sm inputtext' placeholder="<?php echo xla('Alt City'); ?>" />
 502     </div>
 503     <div class="col-auto">
 504         <label for="form_state2" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Alt State') . "/" . xlt('county'); ?>:</label>
 505     </div>
 506     <div class="col-auto">
 507     <?php echo generate_select_list('form_state2', 'state', ($row['state2'] ?? null), '', 'Unassigned', 'form-control-sm', 'typeSelect(this.value)'); ?>
 508     </div>
 509     <div class="col-auto">
 510         <label for="form_zip2" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Alt Postal code'); ?>:</label>
 511     </div>
 512     <div class="col-auto">
 513         <input type='text' size='10' name='form_zip2' maxlength='20' value='<?php echo attr($row['zip2'] ?? ''); ?>' class='form-control form-control-sm inputtext' placeholder="<?php echo xla('Alt Postal code'); ?>" />
 514     </div>
 515 </div>
 516
 517 <div class="form-row my-1">
 518     <div class="col-auto">
 519         <label for="form_upin" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('UPIN'); ?>:</label>
 520     </div>
 521     <div class="col-auto">
 522         <input type='text' size='6' name='form_upin' maxlength='6' value='<?php echo attr($row['upin'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 523    </div>
 524    <div class="col-auto">
 525         <label for="form_npi" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('NPI'); ?>:</label>
 526    </div>
 527    <div class="col-auto">
 528         <input type='text' size='10' name='form_npi' maxlength='10' value='<?php echo attr($row['npi'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 529    </div>
 530    <div class="col-auto">
 531         <label for="form_federaltaxid" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('TIN'); ?>:</label>
 532    </div>
 533    <div class="col-auto">
 534         <input type='text' size='10' name='form_federaltaxid' maxlength='10' value='<?php echo attr($row['federaltaxid'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 535     </div>
 536     <div class="col-auto">
 537         <label for="form_taxonomy" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Taxonomy'); ?>:</label>
 538     </div>
 539    <div class="col-auto">
 540         <input type='text' size='10' name='form_taxonomy' maxlength='10' value='<?php echo attr($row['taxonomy'] ?? ''); ?>' class='form-control form-control-sm inputtext' />
 541    </div>
 542 </div>
 543 <div class="form-group">
 544     <label for="form_notes" class="font-weight-bold col-form-label col-form-label-sm"><?php echo xlt('Notes'); ?>:</label>
 545     <textarea rows='3' cols='40' name='form_notes' wrap='virtual' class='form-control inputtext w-100'><?php echo text($row['notes'] ?? '') ?></textarea>
 546 </div>
 547
 548 <br />
 549
 550 <input type='submit' class='btn btn-primary' name='form_save' value='<?php echo xla('Save'); ?>' />
 551
 552 <?php if ($userid && !$row['username']) { ?>
 553 &nbsp;
 554 <input type='submit' class='btn btn-danger' name='form_delete' value='<?php echo xla('Delete'); ?>' />
 555 <?php } ?>
 556
 557 &nbsp;
 558 <input type='button' class='btn btn-secondary' value='<?php echo xla('Cancel'); ?>' onclick='window.close()' />
 559 </p>
 560 </form>
 561 <?php    $use_validate_js = 1;?>
 562 <?php validateUsingPageRules($_SERVER['PHP_SELF']);?>
 563 </body>
 564 </html>