DEWATA [ login.easenup.in ]

Name	Size	Permission
assets	[ DIR ]	drwxr-xr-x
db	[ DIR ]	drwxr-xr-x
includes	[ DIR ]	drwxr-xr-x
RegisterNow.php	8.47 KB	-rw-r--r--
add-allergies.php	11.58 KB	-rw-r--r--
add-immunization.php	10.58 KB	-rw-r--r--
add-pateint.php	18.4 KB	-rw-r--r--
add-vault-medical-document.php	11.55 KB	-rw-r--r--
allergies.php	10.15 KB	-rw-r--r--
basic-info.php	9.89 KB	-rw-r--r--
contact-details.php	10.58 KB	-rw-r--r--
dashboard.php	25.75 KB	-rw-r--r--
family.php	4.5 KB	-rw-r--r--
immunization.php	10.57 KB	-rw-r--r--
index.php	58 B	-rw-r--r--
insurance-details.php	9.8 KB	-rw-r--r--
kin-details.php	10.93 KB	-rw-r--r--
login.php	6.45 KB	-rw-r--r--
medical-condition.php	12.32 KB	-rw-r--r--
medication.php	12.91 KB	-rw-r--r--
personal-details.php	10.14 KB	-rw-r--r--
timeline.php	9.91 KB	-rw-r--r--
username-checker.php	1.28 KB	-rw-r--r--
vault-medical-document.php	10.1 KB	-rw-r--r--

Code Editor : add-vault-medical-document.php

<!DOCTYPE html>
<html lang="en">
	<head>
		<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1" />
		<meta charset="utf-8" />
		<title>Add Vault Medical Document</title>

<link rel="stylesheet" href="assets/css/bootstrap.min.css" />
		<link rel="stylesheet" href="assets/font-awesome/4.5.0/css/font-awesome.min.css" />

<link rel="stylesheet" href="assets/css/fonts.googleapis.com.css" />

<link rel="stylesheet" href="assets/css/ace.min.css" class="ace-main-stylesheet" id="main-ace-style" />

<link rel="stylesheet" href="assets/css/ace-skins.min.css" />
		<link rel="stylesheet" href="assets/css/ace-rtl.min.css" />

<script src="assets/js/ace-extra.min.js"></script>

</head>

<div class="main-container ace-save-state" id="main-container">
			<script type="text/javascript">
				try{ace.settings.loadState('main-container')}catch(e){}
			</script>

<div id="sidebar" class="sidebar                     navbar-collapse collapse          ace-save-state">
				<script type="text/javascript">
					try{ace.settings.loadState('sidebar')}catch(e){}
				</script>

<?php include('includes/sidebar.php'); ?>

<li class="active">
								<a href="#">Add Vault Medical Document</a>
							</li>

</ul>

<div class="ace-settings-box clearfix" id="ace-settings-box">
								<div class="pull-left width-50">
									<div class="ace-settings-item">
										<div class="pull-left">
											<select id="skin-colorpicker" class="hide">
												<option data-skin="no-skin" value="#438EB9">#438EB9</option>
												<option data-skin="skin-1" value="#222A2D">#222A2D</option>
												<option data-skin="skin-2" value="#C6487E">#C6487E</option>
												<option data-skin="skin-3" value="#D0D0D0">#D0D0D0</option>
											</select>
										</div>
										<span>&nbsp; Choose Skin</span>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-navbar" autocomplete="off" />
										<label class="lbl" for="ace-settings-navbar"> Fixed Navbar</label>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-sidebar" autocomplete="off" />
										<label class="lbl" for="ace-settings-sidebar"> Fixed Sidebar</label>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-breadcrumbs" autocomplete="off" />
										<label class="lbl" for="ace-settings-breadcrumbs"> Fixed Breadcrumbs</label>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-rtl" autocomplete="off" />
										<label class="lbl" for="ace-settings-rtl"> Right To Left (rtl)</label>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2 ace-save-state" id="ace-settings-add-container" autocomplete="off" />
										<label class="lbl" for="ace-settings-add-container">
											Inside
											<b>.container</b>
										</label>
									</div>
								</div>

<div class="pull-left width-50">
									<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-hover" autocomplete="off" />
										<label class="lbl" for="ace-settings-hover"> Submenu on Hover</label>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-compact" autocomplete="off" />
										<label class="lbl" for="ace-settings-compact"> Compact Sidebar</label>
									</div>

<div class="ace-settings-item">
										<input type="checkbox" class="ace ace-checkbox-2" id="ace-settings-highlight" autocomplete="off" />
										<label class="lbl" for="ace-settings-highlight"> Alt. Active Item</label>
									</div>
								</div>
							</div>
						</div>

<div class="page-header">
							<h1>Add Vault Medical Document </h1>
						</div>

<div class="row">
							<div class="col-xs-12">
								
								<div class="row">
									<div class="col-xs-12">
                                    <form method="post" action="" id="myForm" name="submit" onsubmit="return validateform()">
  <table id="example2" class="table table-bordered table-hover">  
      <tbody>
	        
            <input type="hidden" name="patientid" id="patientid" value="35267"><input type="hidden" name="familyid" id="familyid" value="35243">                  <tr>
          <td height="62"> Date of issue</td>
          <td><input type="date" placeholder="Name of Kin" name="name" class='form-control'></td>
        </tr>
		 <tr>
          <td height="62">Issue By</td>
          <td><input type="date" placeholder="Mobile Number" name="mobileno" class='form-control'>
</td>
        </tr>
            <tr>
          <td height="62"> Type of Document</td>
          <td><select name="typedocument" id="typedocument" class='form-control'>
<option value="" disabled="" selected="">Type of Document </option>
<option value="OPD"> OPD</option>
 <option value="IPD">IPD</option>
<option value="Investigation"> Investigation</option> 
<option value="Medical Bill"> Medical Bill </option>
<option value="Discharge Summary"> Discharge Summary</option>
</select>
<br>
      <input type="checkbox" id="myCheck2" onclick="myFunction2()" name="ifother"><span> If Other</span>
      
 
  <p id="text2" style="display:none">
       <label>Specify</label>
  <input type="text" name="Specify" id="Specify" class='form-control'>
  </p>
</td>
        </tr>

<tr>
          <td height="62">Upload Document</td>
          <td><input type="file" name="fileToUpload" id="fileToUpload">
</td>
        </tr>

</div>
						</div>

</div>
						</div>

</div>
				</div>
			</div>

<div class="footer">
				<div class="footer-inner">
					<div class="footer-content">
						<span class="bigger-120">
							<span class="blue bolder">Ace</span>
							Application &copy; 2013-2014
						</span>

&nbsp; &nbsp;
						<span class="action-buttons">
							<a href="#">
								<i class="ace-icon fa fa-twitter-square light-blue bigger-150"></i>
							</a>

<script src="assets/js/jquery-2.1.4.min.js"></script>

<script type="text/javascript">
			if('ontouchstart' in document.documentElement) document.write("<script src='assets/js/jquery.mobile.custom.min.js'>"+"<"+"/script>");
		</script>
		<script src="assets/js/bootstrap.min.js"></script>

<script src="assets/js/ace-elements.min.js"></script>
		<script src="assets/js/ace.min.js"></script>

<script>
function myFunction2() {
  var checkBox = document.getElementById("myCheck2");
  var text = document.getElementById("text2");
  if (checkBox.checked == true){
    text.style.display = "block";
  } else {
     text.style.display = "none";
  }
}</script>

</body>
</html>

${this.title}

Code Editor : add-vault-medical-document.php