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<!-- Content Wrapper. Contains page content -->
<div class="content-wrapper">
<!-- Content Header (Page header) -->
<section class="content-header">
<h1>Add New Doctor</h1>
</section>
<!-- Main content -->
<section class="content">
<div class="row">
<div class="col-md-12">
<?php
if($this->session->flashdata('message')) {
$message = $this->session->flashdata('message');
?>
<div class="callout callout-<?php echo $message['class']; ?>" id="successMessage">
<h4><?php echo $message['title']; ?></h4>
<p><?php echo $message['message']; ?></p>
</div>
<?php
}
?>
<!-- general form elements -->
<form method="post" data-parsley-validate="" class="validate" role="form" enctype="multipart/form-data">
<div class="box box-solid box-info">
<div class="box-header">
<h3 class="box-title">PERSONAL DATA</h3>
</div><!-- /.box-header -->
<!-- form start -->
<div class="box-body">
<div class="row">
<div class="form-group col-md-6">
<label>Email</label>
<input name="reg_pat_email" data-parsley-maxlength="100" type="text" data-parsley-required="true" data-parsley-email="" data-parsley-emailalreadyexist="" class="ip_reg_form_input form-control reset-form-custom" pattern="[a-z0-9._%+-]+@[a-z0-9.-]+\.[a-z]{2,3}$" placeholder="E-mail" id="reg-form-email" >
</div>
<div class="form-group col-md-6">
<label>RG</label>
<input name="reg_pat_rg" data-parsley-maxlength="25" type="text" class="ip_reg_form_input form-control reset-form-custom" placeholder="RG">
</div>
</div>
<div class="row">
<div class="form-group col-md-6">
<label>CPF</label>
<input name="reg_pat_cpf" data-parsley-required="true" data-parsley-length="[11,11]" type="number" class="ip_reg_form_input form-control reset-form-custom" placeholder="CPF" data-parsley-cpf="">
</div>
<div class="form-group col-md-6">
<label>CRM</label>
<input name="reg_pat_crm" data-parsley-maxlength="25" type="text" class="ip_reg_form_input form-control reset-form-custom" placeholder="CRM">
</div>
</div>
<div class="row">
<div class="form-group col-md-6">
<label>Specialization</label>
<select class="form-control" data-placeholder="Select a State"
style="width: 100%;" name="specialization" data-parsley-required>
<option value="-1">Select Your Specialization</option>
<?php
foreach ($data as $key => $value)
{
?>
<option value="<?php echo $value['id'] ?>"><?php echo $value["specialization_name"] ?></option>
<?php
}
?>
</select>
</div>
<div class="form-group col-md-6">
<label>Price</label>
<input name="price" data-parsley-length="[2,5]" type="number" class="ip_reg_form_input form-control reset-form-custom" data-parsley-required="true" placeholder="PRICE">
</div>
<div class="form-group col-md-6" >
<label>Date of Birth</label>
<div class="input-group date" id="sandbox-container">
<div class="input-group-addon">
<i class="fa fa-calendar"></i>
</div>
<input name="reg_pat_dob" class="ip_reg_form_input form-control reset-form-custom" data-parsley-required="true"/>
</div>
</div>
<div class="form-group col-md-6">
<div class="ip_day_time_schedule_details_data p0 floatLeft ip_gender_check">
<label for="reg-form-patient-male" class="ip_custom_checkbox_label1 ip_gender_check_label">Male</label>
<input id="reg-form-patient-male" class="ip_custom_checkbox1 ip_gender_check_checkbox " name="reg_pat_gender" type="radio" value="MALE">
</div>
<div class="ip_day_time_schedule_details_data p0 floatLeft ip_gender_check">
<label for="reg-form-patient-female" class="ip_custom_checkbox_label1 ip_gender_check_label">Female</label>
<input id="reg-form-patient-female" class="ip_custom_checkbox1 ip_gender_check_checkbox " name="reg_pat_gender" type="radio" value="FEMALE">
</div>
<div class="ip_day_time_schedule_details_data p0 floatLeft ip_gender_check">
<label for="reg-form-patient-others" class="ip_custom_checkbox_label1 ip_gender_check_label">Others</label>
<input id="reg-form-patient-others" class="ip_custom_checkbox1 ip_gender_check_checkbox " name="reg_pat_gender" type="radio" value="OTHERS" data-parsley-required="true">
</div>
</div>
</div>
</div>
</div>
<div class="box box-solid box-info">
<div class="box-header with-border">
<h3 class="box-title">ADDRESS</h3>
</div>
<div class="box-body">
<div class="form-group col-md-6">
<label>CEP</label>
<input data-parsley-required name="reg_pat_cep" data-parsley-length="[8,8]" type="number" class="ip_reg_form_input reset-form-custom form-control" placeholder="CEP" id="doctor_cep" data-parsley-cep="">
</div>
<div class="form-group col-md-6">
<label>RUA </label>
<input data-parsley-required name="reg_pat_streetadd" data-parsley-maxlength="50" type="text" class="ip_reg_form_input reset-form-custom form-control" placeholder="Rua" id="doctor_rua">
</div>
<div class="form-group col-md-6">
<label>Neighborhood </label>
<input data-parsley-required data-parsley-maxlength="50" name="reg_pat_locality" type="text" class="ip_reg_form_input reset-form-custom form-control" placeholder="Neighborhood">
</div>
<div class="form-group col-md-6">
<label>Number </label>
<input data-parsley-required data-parsley-maxlength="30" name="reg_pat_number" type="text" class="ip_reg_form_input reset-form-custom form-control" placeholder="Number">
</div>
<div class="form-group col-md-12">
<label>Complement </label>
<input data-parsley-maxlength="50" name="reg_pat_complement" type="text" class="ip_reg_form_input reset-form-custom form-control" placeholder="Complement">
</div>
</div>
</div>
<div class="box box-solid box-info">
<div class="box-header">
<h3 class="box-title">LOGIN AND PASSWORD</h3>
</div>
<div class="box-body">
<div class="form-group">
<label>Name </label>
<input data-parsley-required id="reg-form-patient-name" data-parsley-pattern="[A-Za-z]+" name="reg_pat_name" data-parsley-length="[5,40]" type="text" class="ip_reg_form_input reset-form-custom form-control" placeholder="Name">
</div>
<div class="form-group">
<label>User Name </label>
<input data-parsley-required data-parsley-username="" data-parsley-unamealreadyexist="" name="reg_pat_username" data-parsley-length="[5,25]" data-parsley-pattern="[A-Za-z0-9]+" type="text" class="ip_reg_form_input reset-form-custom form-control" placeholder="User Name">
</div>
<div class="form-group">
<label>Password</label>
<div class="input-group">
<input id="reg-form-pass" data-parsley-required name="reg_pat_password" data-parsley-length="[8,25]" type="password" class="ip_reg_form_input reset-form-custom form-control" placeholder="Password">
<span class="input-group-btn">
<button class="btn btn-flat show-pwd-btn" type="button">
<i class="fa fa-eye"></i>
</button>
</span>
</div>
</div>
<div class="form-group">
<label>Confirm Password</label>
<div class="input-group">
<input data-parsley-equalto="#reg-form-pass" data-parsley-required name="reg_pat_confirmpassword" data-parsley-length="[8,25]" type="password" class="ip_reg_form_input reset-form-custom form-control" placeholder="Confirm Password">
<span class="input-group-btn">
<button class="btn btn-flat show-pwd-btn" type="button">
<i class="fa fa-eye"></i>
</button>
</span>
</div>
</div>
</div>
</div>
<div class="box box-solid box-info">
<div class="box-header">
<h3 class="box-title">ADDITIONAL DATA</h3>
</div>
<div class="box-body">
<div class="form-group">
<label>Profile Picture</label>
<input name="profile_pic" id="profile_pic" type="file" data-parsley-required class="required" accept="image/*" onchange="readURL(this)" style="display: none;">
<div>
<img alt="" style="width:100px; height:100px" id="preview_profile_pic" />
</div>
</div>
<div class="form-group">
<label>Biography</label>
<textarea name="reg_pat_biography" data-parsley-length="[15,500]" type="text" class="ip_reg_form_input form-control reset-form-custom" placeholder="Biography" data-parsley-required></textarea>
</div>
<!-- <div class="form-group">
<label>Photos</label>
<input name="multiple_pic[]" id="multiple_pic" type="file" multiple accept="image/*" style="display: none;" onchange="readURL_multiple(this)">
<input name="filearray[]" id="filearray" style="display:none" value=""/>
<div id="preview_multiple_pic">
</div>
<div id="preview_multiple_cpypic">
</div>
</div> -->
</div>
<div class="box-footer">
<button type="submit" class="btn btn-info btn-lg">Submit</button>
</div>
</div>
</form>
<!--/.col (Add) -->
</div> <!-- /.row -->
</section><!-- /.content -->
</div>
<!-- /.content-wrapper -->