contrib/forms/contacts/new.php

   1 <?php
   2
   3 /**
   4  * contacts new.php
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    andres_paglayan <andres_paglayan>
   9  * @author    sunsetsystems <sunsetsystems>
  10  * @author    cornfeed <jdough823@gmail.com>
  11  * @author    fndtn357 <fndtn357@gmail.com>
  12  * @author    Brady Miller <brady.g.miller@gmail.com>
  13  * @author    Daniel Ehrlich <daniel.ehrlich1@gmail.com>
  14  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  15  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  16  * @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com>
  17  * @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com>
  18  * @copyright Copyright (c) 2018 Brady Miller <brady.g.miller@gmail.com>
  19  * @copyright Copyright (c) 2018 Daniel Ehrlich <daniel.ehrlich1@gmail.com>
  20  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  21  */
  22
  23 ?>
  24 <!-- Form generated from formsWiz -->
  25 <?php
  26 require_once("../../globals.php");
  27 require_once("$srcdir/api.inc.php");
  28
  29 use OpenEMR\Common\Csrf\CsrfUtils;
  30 use OpenEMR\Core\Header;
  31
  32 formHeader("Form: contacts");
  33 ?>
  34 <html><head>
  35     <?php Header::setupHeader(); ?>
  36 </head>
  37 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  38 <form method=post action="<?php echo $rootdir;?>/forms/contacts/save.php?mode=new" name="my_form">
  39 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
  40 <span class="title">Contacts</span><br /><br />
  41 <table>
  42 <tr>
  43 <td valign=top>
  44 <table>
  45 <tr><td><span class=text>OD Base Curve: </span></td><td><input size=4 type="text" name="od_base_curve" value="" ></td></tr>
  46 <tr><td><span class=text>OD Sphere: </span></td><td><input size=4 type="text" name="od_sphere" value="" ></td></tr>
  47 <tr><td><span class=text>OD Cylinder: </span></td><td><input size=4 type="text" name="od_cylinder" value="" ></td></tr>
  48 <tr><td><span class=text>OD Axis: </span></td><td><input size=4 type="text" name="od_axis" value="" ></td></tr>
  49 <tr><td><span class=text>OD Diameter: </span></td><td><input size=4 type="text" name="od_diameter" value="" ></td></tr>
  50 </table>
  51 </td>
  52 <td valign=top>
  53 <table>
  54 <tr><td><span class=text>OS Base Curve: </span></td><td><input size=4 type="text" name="os_base_curve" value="" ></td></tr>
  55 <tr><td><span class=text>OS Sphere: </span></td><td><input size=4 type="text" name="os_sphere" value="" ></td></tr>
  56 <tr><td><span class=text>OS Cylinder: </span></td><td><input size=4 type="text" name="os_cylinder" value="" ></td></tr>
  57 <tr><td><span class=text>OS Axis: </span></td><td><input size=4 type="text" name="os_axis" value="" ></td></tr>
  58 <tr><td><span class=text>OS Diameter: </span></td><td><input size=4 type="text" name="os_diameter" value="" ></td></tr>
  59 </table>
  60 </td>
  61 </tr>
  62 </table>
  63
  64 <table>
  65 <tr><td><span class=text>Material: </span></td><td><input size=4 type="text" name="material" value="" ></td>
  66 <td><span class=text>Color: </span></td><td><input size=4 type="text" name="color" value="" ></td>
  67 <td><span class=text>Bifocal Type: </span></td><td><input size=4 type="text" name="bifocal_type" value="" ></td>
  68 <td><span class=text>Add: </span></td><td><input size=4 type="text" name="add_value" value="" ></td>
  69 <td><span class=text>V/A Far: </span></td><td><input size=4 type="text" name="va_far" value="" ></td>
  70 <td><span class=text>V/A Near: </span></td><td><input size=4 type="text" name="va_near" value="" ></td>
  71 </tr>
  72 </table>
  73
  74 <table>
  75 <tr>
  76 <td valign=top>
  77 <span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea><br />
  78 </td>
  79 </tr>
  80 </table>
  81 <br />
  82 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  83 <br />
  84 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  85  onclick="top.restoreSession()">[Don't Save]</a>
  86 </form>
  87 <?php
  88 formFooter();
  89 ?>