<div class="content-wrapper">
<section class="content-header">
<h1>
<?= $page_title ?>
<small><?= $page_desc ?></small>
</h1>
<ol class="breadcrumb">
<li><a href="<?= base_url() ?>"><i class="fa fa-star-o" aria-hidden="true"></i>Home</a></li>
<li><?= $menu ?></li>
<li class="active"><?= $sub_menu ?></li>
</ol>
</section>
<section class="content">
<div class="row">
<div class="col-md-12">
<?php
$redirectUrl = (isset($customer_id) && !empty($customer_id))
?'Customer/updateCustomer/'.$customer_id
:'Customer/createCustomer';
if($this->session->flashdata('message')) {
$flashdata = $this->session->flashdata('message'); ?>
<div class="alert alert-<?= $flashdata['class'] ?>">
<button class="close" data-dismiss="alert" type="button">×</button>
<?= $flashdata['message'] ?>
</div>
<?php } ?>
</div>
<div class="col-md-12">
<div class="box box-warning">
<div class="box-header with-border">
<h3 class="box-title">Personal Details</h3>
</div>
<form role="form" action="<?=base_url($redirectUrl)?>" method="post" class="validate" data-parsley-validate="" enctype="multipart/form-data">
<div class="box-body">
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>First Name</label>
<input type="text" class="form-control required" data-parsley-trigger="change"
data-parsley-minlength="2" data-parsley-pattern="^[a-zA-Z\ . ! @ # $ % ^ & * () + = , \/]+$"
required="" name="first_name" placeholder="Enter Patient First Name"
value="<?= (isset($customer_data) && isset($customer_data->first_name))?$customer_data->first_name:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Last Name</label>
<input type="text" class="form-control required" data-parsley-trigger="change"
data-parsley-minlength="2" data-parsley-pattern="^[a-zA-Z\ . ! @ # $ % ^ & * () + = , \/]+$" required="" name="last_name" placeholder="Enter Patient Last Name"
value="<?= (isset($customer_data) && isset($customer_data->last_name))?$customer_data->last_name:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
</div>
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Email</label>
<input type="email" class="form-control required" data-parsley-trigger="change"
data-parsley-minlength="2" required="" name="email" placeholder="Enter Patient Email"
value="<?= (isset($customer_data) && isset($customer_data->email))?$customer_data->email:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Phone</label>
<input type="number" class="form-control required" data-parsley-trigger="change"
data-parsley-minlength="2" required="" name="phone" placeholder="Enter Patient Phone"
value="<?= (isset($customer_data) && isset($customer_data->phone))?$customer_data->phone:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
</div>
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Date Of Birth</label>
<div class="input-group date" data-provide="datepicker">
<input id="datepicker" type="text" class="form-control required" data-parsley-trigger="change" data-parsley-minlength="2" required="" name="date_of_birth" placeholder="Pick Date Of Birth" autocomplete="off" value="<?= (isset($customer_data) && isset($customer_data->date_of_birth))?$customer_data->date_of_birth:'' ?>">
<div class="input-group-addon">
<i class="fa fa-calendar"></i>
</div>
</div>
</div>
</div>
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Alternate Phone</label>
<input type="number" class="form-control" data-parsley-trigger="change"
data-parsley-minlength="2" name="alt_phone" placeholder="Enter Alternate Phone"
value="<?= (isset($customer_data) && isset($customer_data->alt_phone))?$customer_data->alt_phone:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
</div>
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Address</label>
<textarea class="form-control required" data-parsley-trigger="change"
data-parsley-minlength="2" required="" name="address" placeholder="Enter Patient Address"><?= (isset($customer_data) && isset($customer_data->address))?trim($customer_data->address):'' ?></textarea>
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label for="exampleInputEmail1">Profile Picture</label>
<div class="col-md-12">
<div class="col-md-3">
<img id="profile_image" src="<?= (isset($customer_data) && isset($customer_data->profile_image))?base_url($customer_data->profile_image):'' ?>" onerror="this.src='<?=base_url("assets/images/user_avatar.jpg")?>'" height="75" width="75" />
</div>
<div class="col-md-9" style="padding-top: 25px;">
<input name="profile_image" type="file" accept="image/*"
class="<?= (isset($customer_id) && !empty($customer_id))?'':'required' ?>"
onchange="setImg(this,'profile_image')" />
</div>
</div>
</div>
</div>
</div>
<div style="border-bottom: 1px solid #f4f4f4;border-bottom-width: 1px;border-bottom-style: solid;
border-bottom-color: rgb(244, 244, 244);">
<h3 class="box-title" style="font-size: 18px !important;">
Medical Details
</h3>
</div><br>
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>SSN</label>
<input type="text" class="form-control" data-parsley-trigger="change"
data-parsley-minlength="2" name="ssn" placeholder="Provide SSN"
value="<?= (isset($customer_data) && isset($customer_data->ssn))?$customer_data->ssn:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
<div class="col-md-6">
<div class="form-group has-feedback">
<label>GRP</label>
<input type="text" class="form-control" data-parsley-trigger="change"
data-parsley-minlength="2" name="grp" placeholder="Provide GRP"
value="<?= (isset($customer_data) && isset($customer_data->grp))?$customer_data->grp:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
</div>
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Issuer</label>
<input class="form-control" data-parsley-trigger="change" data-parsley-minlength="2"
type="text" name="issuer" placeholder="Provide Issuer"
value="<?= (isset($customer_data) && isset($customer_data->issuer))?$customer_data->issuer:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Insurance Provider</label>
<input class="form-control" data-parsley-trigger="change" data-parsley-minlength="2"
type="text" name="insurance_provider" placeholder="Provide Insurance Provider"
value="<?= (isset($customer_data) && isset($customer_data->insurance_provider))?$customer_data->insurance_provider:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
</div>
<div class="col-md-12">
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Member ID</label>
<input class="form-control" data-parsley-trigger="change" data-parsley-minlength="2"
type="text" name="member_id" placeholder="Provide Member ID"
value="<?= (isset($customer_data) && isset($customer_data->member_id))?$customer_data->member_id:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
<div class="col-md-6">
<div class="form-group has-feedback">
<label>Group Number</label>
<input class="form-control" data-parsley-trigger="change" data-parsley-minlength="2"
type="text" name="group_number" placeholder="Provide Group Number"
value="<?= (isset($customer_data) && isset($customer_data->group_number))?$customer_data->group_number:'' ?>">
<span class="glyphicon form-control-feedback"></span>
</div>
</div>
</div>
<div class="col-md-12">
<div class="box-footer">
<div style="text-align: center;">
<button type="submit" class="btn btn-primary">Submit</button>
</div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</section>
</div>