1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
<div class="ip_set_two_wrapper">
<div class="container ip_custom_container">
<?php
if($this->session->flashdata('message')) {
$message = $this->session->flashdata('message');
?>
<div class="alert alert-<?php echo $message['class']; ?> alert-dismissible flash-msg">
<button type="button" class="close" data-dismiss="alert" aria-hidden="true">×</button>
<h4><strong> <?php echo $message['title']; ?></strong></h4>
<?php echo $message['message']; ?>
</div>
<?php
}
?>
<div class="ip_edit_record_wrapper">
<div class="row">
<div class="col-md-12">
<div class="ip_edit_record_cover">
<form role="form" data-parsley-validate="" id="pat-edt-depend-form" method="POST" action="<?php echo base_url();?>Patient/updateDependent" enctype="multipart/form-data">
<div class="ip_edit_record_head backgroundnone">
<?php load_language('edit_dependent');?>
</div>
<div class="ip_edit_record_detail">
<div class="ip_edit_row">
<div class="ip_bank_detail_frame">
<input name="dependent_name" class="ip_bank_input" data-parsley-required="true" data-parsley-minlength="5" onKeyPress="if(this.value.length > 40) return false;" data-parsley-maxlength="40" data-parsley-pattern="^[a-zA-Z ]+$" type="text" placeholder="<?php load_language('name');?>" value="<?php echo $dependent_detail['dependent_name']?>">
<input type="hidden" name="dependent_id" value="<?php echo $dependent_detail['id']?>">
</div>
</div>
<div class="ip_edit_row">
<div class="row">
<div class="col-md-3">
<p class="ip_row_p"><?php load_language('date_of_birth');?></p>
<div class="ip_bank_detail_frame" id="edit-patient-dependent">
<input name="dob" id="pat-edt-dependent-dob" readonly data-parsley-required="true" class="ip_bank_input" placeholder="">
</div>
</div>
<div class="col-md-3">
<p class="ip_row_p"><?php load_language('family_bond');?></p>
<div class="ip_bank_detail_frame">
<input name="relation" data-parsley-required="true" data-parsley-minlength="5" data-parsley-maxlength="25" onKeyPress="if(this.value.length > 25) return false;" class="ip_bank_input" placeholder="" data-parsley-pattern="^[a-zA-Z ]+$" value="<?php echo $dependent_detail['relation']?>">
</div>
</div>
<div class="col-md-3">
<p class="ip_row_p">CPF</p>
<div class="ip_bank_detail_frame">
<input class="ip_bank_input" placeholder="" name="cpf"
data-parsley-required="true" data-parsley-minlength="11" data-parsley-cpf="" onKeyPress="if(this.value.length > 10) return false;" value="<?php echo $dependent_detail['cpf']?>" type="number">
</div>
</div>
<div class="col-md-3">
<p class="ip_row_p"><?php load_language('add_photo');?>:</p>
<div class="ip_reg_modal_addphoto floatLeft">
<img id="pat-edit-depend-pic" src="<?php echo base_url(); echo $dependent_detail['image']?>">
</div>
<div class="ip_add_photo floatRight">
<input name="image" type="file" accept="image/*" class="ip_reg_form_input"
data-parsley-error-message="<?php load_language('profile_photo_error_text');?>" onchange="pat_add_depend_loadthumbnail(this,'pat-edit-depend-pic')" >
</div>
<div class="clear"></div>
</div>
</div>
</div>
</div>
<hr>
<div class="ip_coloborator_btn_bay">
<button class="ip_colaborator_btn"><?php load_language('update_and_save');?></button>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</div>