{% extends 'base.html.twig' %}

{% block title %}New Case{% endblock %}

{% block content %}
<form method="post" class="kt-form">
    <div class="kt-container kt-grid__item kt-grid__item--fluid">
        <div class="kt-portlet kt-portlet--mobile">
            <div class="kt-portlet__head kt-portlet__head--lg">
                <div class="kt-portlet__head-label">
                    <h3 class="kt-portlet__head-title">Add Q Making</h3>
                </div>

                <div class="kt-portlet__head-toolbar">
                    <div class="kt-portlet__head-wrapper">
                        <a href="#" class="btn btn-clean btn-icon-sm mr-2"><i class="la la-long-arrow-left"></i>Back</a>
                        <a href="{{ app.request.uri }}" class="btn btn-secondary btn-bold mr-2">Reset</a>
                        <button class="btn btn-primary btn-bold" id="btn-ward">Submit</button>
                    </div>
                </div>
            </div>

            <div class="kt-portlet__body">
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Patient Name</label>
                    <div class="col-lg-9 col-xl-6">
                        <select name="Doctor" class="form-control">
                            
                    </div>

                </div>

                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">ABHA ID hhk</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>

                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">MRD No.</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>

                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Mobile No.</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Address</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Alternate Address</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Email Address</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Select OPD/IPD/OT/ICU/LAB/Radiology</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                            
                            <option value="">Select OPD/IPD/OT/ICU/LAB/Radiology</option>
                            <option value="OPD">OPD</option>
                            <option value="IPD">IPD</option>
                            <option value="ICU">ICU</option>
                            <option value="Lab">Lab</option>
                            <option value="OT">OT</option>
                            <option value="Radiology">Radiology</option>
                        </select>
                    </div>
                </div>
                
                <div class="form-group row">
                    
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Select Department</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                           
                        </select>
                    </div>
                </div>
                
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Token No</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                            <option value="">Select Token</option>
                            <option value="">OPD-ENT-001</option>
                            <option value="">OPD-ENT-002</option>
                            <option value="">OPD-ENT-003</option>
                            <option value="">OPD-ENT-004</option>
                            <option value="">OPD-ENT-005</option>
                            <option value="">OPD-ENT-006</option>
                            <option value="">OPD-ENT-007</option>
                            <option value="">OPD-ENT-008</option>
                            <option value="">OPD-ENT-009</option>
                            <option value="">OPD-ENT-010</option>
                            <option value="">OPD-ENT-011</option>
                            <option value="">OPD-ENT-012</option>
                            <option value="">OPD-ENT-013</option>
                            <option value="">OPD-ENT-014</option>
                            <option value="">OPD-ENT-015</option>
                            
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Type of Doctor</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                            <option value="">Select Doctor</option>
                        <option value="Specialist Doctor">Specialist Doctor</option>
                        <option value="M.B.B.S">M.B.B.S</option>
                        <option value="Dentist">Dentist</option>
                        <option value="Ayurvedic">Ayurvedic</option>
                        <option value="Homeopathy">Homeopathy</option>
                        <option value="Physiotherapist">Physiotherapist</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Name of Doctor</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                            <option value="">Select Doctor</option>
                            <option value="">Dr. Ankita Agrawal</option>
                            <option value="">jeni jack</option>
                            <option value="">hit zala</option>
                            <option value="">virendra vgf</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Priority</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                            <option value="1">Delivery case</option>
                            <option value="2">Registration and Appointment</option>
                            <option value="3">New OPD Patient for check up </option>
                            <option value="4">Emergency case</option>
                            <option value="5">Appointment </option>
                            <option value="6">Appointment for follow up</option>
                            <option value="7">Reffreral in Case</option>
                            <option value="8">Normal</option>
                            <option value="9">VIP</option>
                            <option value="10">Trauma</option>
                            <option value="11">Cardiac</option>
                            <option value="12">ICU</option>
                            
                        </select>
                    </div>
                </div>
                {# <div class="form-group row">
                    <label class="col-3 col-form-label font-weight-bold">Priority</label>

                    <div class="col-9">
                        <div class="kt-radio-inline">
                            <label class="kt-radio">
                                <input type="radio" id="pay-chrg" name="pay_type" class="kt-radio" value="chrg"
                                    checked>
                                <label for="pay-chrg">Normal</label>
                                <span></span>
                            </label>

                            <label class="kt-radio">
                                <input type="radio" id="pay-free" name="pay_type" class="kt-radio" value="free">
                                <label for="pay-free">VIP</label>
                                <span></span>
                            </label>
                            <label class="kt-radio">
                                <input type="radio" id="pay-free" name="pay_type" class="kt-radio" value="free">
                                <label for="pay-free">Trauma</label>
                                <span></span>
                            </label>
                            <label class="kt-radio">
                                <input type="radio" id="pay-free" name="pay_type" class="kt-radio" value="free">
                                <label for="pay-free">Cardiac</label>
                                <span></span>
                            </label>
                            <label class="kt-radio">
                                <input type="radio" id="pay-free" name="pay_type" class="kt-radio" value="free">
                                <label for="pay-free">ICU</label>
                                <span></span>
                            </label>
                        </div>
                    </div>
                </div> #}
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Room No.</label>
                    <div class="form-group">
                        <select name="Doctor" class="form-control">
                            <option value="">Select Room No</option>
                            <option value="1">1</option>
                            <option value="2">2</option>
                            <option value="3">3</option>
                            <option value="4">4</option>
                            <option value="5">5</option>
                            <option value="6">6</option>
                            <option value="7">7</option>
                            <option value="8">8</option>
                            <option value="9">9</option>
                            <option value="10">10</option>
                            <option value="11">11</option>
                            <option value="12">12</option>
                            <option value="13">13</option>
                            <option value="14">14</option>
                            <option value="15">15</option>
                            <option value="16">16</option>
                            <option value="17">17</option>
                            <option value="18">18</option>
                            <option value="19">19</option>
                            <option value="20">20</option>
                        </select>
                    </div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Date</label>
                    <div class="col-lg-9 col-xl-6"><input type="date" class="form-control date"></div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Time slot</label>
                    <div class="col-lg-9 col-xl-6">

                        <div class="form-group">
                            <select name="timeslot" class="form-control">
                                <option value="">Select Room No</option>
                                <option value="1">8:00 AM To 8:30 AM</option>
                                <option value="1">8:30 AM To 9:00 AM</option>
                                <option value="1">9:00 AM To 9:30 AM</option>
                                <option value="1">9:30 AM To 10:00 AM</option>
                                <option value="1">10:00 AM To 10:30 AM</option>
                                <option value="1">10:30 AM To 11:00 AM</option>
                                <option value="1">11:00 AM To 11:30 AM</option>
                                <option value="1">11:30 AM To 12:00 PM</option>
                                <option value="1">12:00 PM To 12:30 PM</option>
                                <option value="1">12:30 PM To 1:00 PM</option>
                                <option value="1">1:00 PM To 1:30 PM</option>
                                <option value="1">1:30 PM To 2:00 PM</option>
                                <option value="1">2:00 PM To 2:30 PM</option>
                                <option value="1">2:30 PM To 3:00 PM</option>
                                <option value="1">3:00 PM To 3:30 PM</option>
                                <option value="1">3:30 PM To 4:00 PM</option>
                                <option value="1">4:00 PM To 4:30 PM</option>
                                <option value="1">4:30 PM To 5:00 PM</option>
                                <option value="1">5:00 PM To 5:30 PM</option>
                                <option value="1">5:30 PM To 6:00 PM</option>
                                <option value="1">6:00 PM To 6:30 PM</option>
                                <option value="1">6:30 PM To 7:00 PM</option>
                                <option value="1">7:00 PM To 7:30 PM</option>
                                <option value="1">7:30 PM To 8:00 PM</option>
                            
                            </select>
                        </div>
                    </div>
                </div>
               
                
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Hospital Consultation</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Teleconsultation</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                <div class="form-group row">
                    <label class="col-xl-3 col-lg-3 font-weight-bold">Message</label>
                    <div class="col-lg-9 col-xl-6"><input type="text" class="form-control"></div>
                </div>
                
                
                
            </div>
        </div>
    </div>
</form>

{% endblock %}