ikan Uploader :
Directory : /var/www/html/shardahospital.org/pdms/application/views/admin/managebooking/
Upload File : |
| Current File : /var/www/html/shardahospital.org/pdms/application/views/admin/managebooking/addprofile.php |
<div id="content-wrapper">
<div class="container-fluid">
<!-- Breadcrumbs-->
<ol class="breadcrumb">
<li class="breadcrumb-item">
<a href="<?php echo site_url('admin/dashboard'); ?>"><i class="fas fa-fw fa-tachometer-alt"></i> Dashboard</a>
</li>
<li class="breadcrumb-item">
<a href="<?php echo site_url('admin/managecovidtest'); ?>"> Covid-19 Test Profile</a>
</li>
<li class="breadcrumb-item active"><?php if($sd['id']>0) { echo 'Edit'; } else { echo 'Add New'; }?> Profile</li>
</ol>
<!-- Page Content -->
<div class="eventfrom">
<div class="card mb-3 fomr-news">
<div class="card-header card-header-new"> <h3><i class="fa fa-plus-circle" aria-hidden="true"></i> <?php if($sd['id']>0) { echo 'Edit'; } else { echo 'Add New'; }?> Profile</h3></div>
</div>
<!---- Success Message ---->
<?php if ($this->session->flashdata('success')) { ?>
<p style="color:green; font-size:18px;"><?php echo $this->session->flashdata('success'); ?></p>
<?php } ?>
<!---- Error Message ---->
<?php if ($this->session->flashdata('error')) { ?>
<p style="color:red; font-size:18px;"><?php echo $this->session->flashdata('error');?></p>
<?php } ?>
<div class="card-body form-body form-body1">
<?php echo form_open('admin/managecovidtest/addprofile',array('enctype'=>'multipart/form-data')); ?>
<input type="hidden" name="id" id="id" value="<?=$sd['id']?>" />
<div class="form-group">
<div class="form-row">
<div class="col-md-12">
<label>Full Name <span style="color:red;">*</span></label>
<div class="form-label-group">
<input type="text" name="full_name" id="full_name" value="<?=$sd['full_name']?>" placeholder="Enter Full Name here" class="form-control" required />
<?php echo form_error('full_name',"<div style='color:red'>","</div>");?>
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="form-row">
<div class="col-md-4">
<label>Contact Number <span style="color:red;">*</span></label>
<div class="form-label-group">
<input type="text" name="contact_number" id="contact_number" value="<?=$sd['contact_number']?>" placeholder="Enter Contact Number" class="form-control" onkeyup="this.value=this.value.replace(/[^\d]/,'')" required />
<?php echo form_error('contact_number',"<div style='color:red'>","</div>");?>
</div>
</div>
<div class="col-md-4">
<label>Email Id</label>
<div class="form-label-group">
<input type="text" name="email_id" id="email_id" value="<?=$sd['email_id']?>" placeholder="Enter Email Id" class="form-control" />
</div>
</div>
<div class="col-md-4">
<label>Age</label>
<div class="form-label-group">
<input type="text" name="age" id="age" value="<?=$sd['age']?>" onkeyup="this.value=this.value.replace(/[^\d]/,'')" placeholder="Enter Age" class="form-control" />
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="form-row">
<div class="col-md-4">
<label>Aadhar Number <span style="color:red;">*</span></label>
<div class="form-label-group">
<input type="text" name="aadhar_number" id="aadhar_number" value="<?=$sd['aadhar_number']?>" placeholder="Enter Aadhar Number" class="form-control" required />
<?php echo form_error('aadhar_number',"<div style='color:red'>","</div>");?>
</div>
</div>
<div class="col-md-8">
<label>Full Address </label>
<div class="form-label-group">
<input type="text" name="address" id="address" value="<?=$sd['address']?>" placeholder="Enter Full Address" class="form-control" />
</div>
</div>
</div>
</div>
<div class="form-group">
<label>Photo ID <span style="color:red;">*</span> </label>
<small>Upload Supporting Files e.g. PDF, Images etc.</small>
<?php if($sd['photo_proof']<>'') { ?>
<p><a href="<?=base_url('attachments/documents/'.$sd['photo_proof'])?>" target="_blank"><i class="fas fa-file"></i> <?=$sd['photo_proof']?></a></p>
<input type="hidden" name="old_photo_proof" value="<?=$sd['photo_proof']?>" />
<?php } ?>
<div class="form-label-group">
<input type="file" id="photo_proof" name="photo_proof" />
</div>
</div>
<div class="form-group">
<div class="form-row">
<div class="col-md-4">
<label>Gender <span style="color:red;">*</span></label>
<div class="form-label-group">
<select class="form-control" name="gender" required>
<option value="">Select ...</option>
<option value="Male" <?php if($sd['gender']=='Male') { echo 'selected'; }?>> Male</option>
<option value="Female" <?php if($sd['gender']=='Female') { echo 'selected'; }?>>Female</option>
<option value="Other" <?php if($sd['gender']=='Other') { echo 'selected'; }?>>Other</option>
</select>
<?php echo form_error('gender',"<div style='color:red'>","</div>");?>
</div>
</div>
<div class="col-md-4">
<label>Do you want collection from home?</label>
<div class="form-label-group">
<select class="form-control" name="onsite_collection" required>
<option value="">Select ...</option>
<option value="No" <?php if($sd['onsite_collection']=='No') { echo 'selected'; }?>> No</option>
<option value="Yes" <?php if($sd['onsite_collection']=='Yes') { echo 'selected'; }?>>Yes</option>
</select>
<?php echo form_error('onsite_collection',"<div style='color:red'>","</div>");?>
</div>
</div>
<div class="col-md-4">
<label>Status <span style="color:red;">*</span> </label>
<div class="form-label-group">
<select class="form-control" name="status" required>
<option value="">Select Status</option>
<option value="1" <?php if($sd['status']==1) { echo 'selected'; }?>> Request Submitted</option>
<option value="2" <?php if($sd['status']==2) { echo 'selected'; }?>>Verification Inprogress</option>
<option value="3" <?php if($sd['status']==3) { echo 'selected'; }?>>Verified</option>
</select>
<?php echo form_error('status',"<div style='color:red'>","</div>");?>
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="form-row">
<div class="col-md-4">
</div>
<div class="col-md-4">
<a href="<?=base_url('admin/managecovidtest')?>" class="btn btn-primary btn-block"> Cancel</a>
<input type="submit" name="save_event" id="save_event" value="Save Profile" class="btn btn-primary btn-block" />
</div>
</div>
</div>
</div>
<?php echo form_close(); ?>
</div>
</div>
</div>
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