interface/new/new.php

   1 <?
   2 include_once("../globals.php");
   3 ?>
   4 <html>
   5
   6 <head>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9
  10 <body <?echo $top_bg_line;?> topmargin='0' rightmargin='0' leftmargin='2'
  11  bottommargin='0' marginwidth='2' marginheight='0'
  12  onload="javascript:document.new_patient.fname.focus();">
  13
  14 <form name='new_patient' method='post' action="new_patient_save.php" target='_top'>
  15 <a class="title" href="../main/main_screen.php" target="_top">New Patient</a>
  16
  17 <br><br>
  18
  19 <center>
  20
  21 <table border='0'>
  22
  23  <tr>
  24   <td>
  25    <span class='bold'>Title: </span>
  26   </td>
  27   <td>
  28    <select name='title'>
  29     <option value="Mr.">Mr.</option>
  30     <option value="Mrs.">Mrs.</option>
  31     <option value="Ms.">Ms.</option>
  32     <option value="Dr.">Dr.</option>
  33    </select>
  34   </td>
  35   <td rowspan='5' class='bold'>
  36   </td>
  37  </tr>
  38
  39  <tr>
  40   <td>
  41    <span class='bold'>First Name: </span>
  42   </td>
  43   <td>
  44    <input type='entry' size='15' name='fname'>
  45   </td>
  46  </tr>
  47
  48  <tr>
  49   <td>
  50    <span class='bold'>Middle Name: </span>
  51   </td>
  52   <td>
  53    <input type='entry' size='15' name='mname'>
  54   </td>
  55  </tr>
  56
  57  <tr>
  58   <td>
  59    <span class='bold'>Last Name: </span>
  60   </td>
  61   <td>
  62    <input type='entry' size='15' name='lname'>
  63   </td>
  64  </tr>
  65
  66  <tr>
  67   <td>
  68    <span class='bold'>Patient Number: </span>
  69   </td>
  70   <td>
  71    <input type='entry' size='5' name='pubpid'>
  72    <span class='text'> omit to autoassign &nbsp; &nbsp; </span>
  73   </td>
  74  </tr>
  75
  76  <tr>
  77   <td colspan='2'>
  78    &nbsp;<br>
  79    <input type='submit' name='form_create' value='Create New Patient' />
  80   </td>
  81   <td>
  82   </td>
  83  </tr>
  84
  85 </table>
  86 </center>
  87 </form>
  88
  89 </body>
  90 </html>