{% extends 'dashboard_screen/base.html' %}

{% block content %}

            <!-- ============================================================== -->
            <!-- Start right Content here -->
            <!-- ============================================================== -->
    <div class="content-page" xmlns="http://www.w3.org/1999/html">
                <!-- Start content -->
                <div class="content">
                    <div class="container">
                        <div class="row">

                            <div class="col-lg-12">
                                 <!-- Basic Form Wizard -->

                            	<div class="card-box">
                            		<h4 class="m-t-0 header-title"><b>New Order Entry Form</b></h4>




									<form id="wizard-validation-form" action="/dashboard/new_entry/" class="group-border-dashed" method="post" enctype="multipart/form-data">
                                        {% csrf_token %}
                                        {% if Patient %}<input type="hidden"  name="patient_id" value="{{ Patient.patient_id }}"/> {% endif %}
                                        <div>
                                            <h3>Patient Information</h3>
                                            <section>
                                                {% if Patient %}
                                                    <h4 class="m-t-0 header-title"><b>Add New Patient</b></h4>
                                                    <div>
                                                           <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>Collection Date:(*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                       <input type="text" class="form-control" name="callection_date" data-date-format="mm/dd/yyyy" placeholder="Collection Date" id="datepicker-autoclose" value="">
                                                                       <span class="input-group-addon bg-custom b-0 text-white"><i class="icon-calender"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-4">
                                                                <div class="p-20">
                                                                    <h5><b>Client Name / Client Code(*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="text" class="form-control" id="id_client_id"  required name="client_id" value="ABCD" />
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa fa-user"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-5">
                                                                <div class="p-20">
                                                                    <h5><b>Attending Physician Name (*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="text" class="form-control" id="state-warning"  required name="patient_first_name" value="aSAS sASasaS" />
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa fa-user"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                            <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>Patient External ID:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="text" class="form-control" id="state-warning" maxlength="25" name="patient_external_id" value="{{ Patient.ext_id }}" onKeyUp="this.value=this.value.toUpperCase();" />
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa-users"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                            <div class="col-lg-4">
                                                                <div class="p-20">
                                                                    <h5><b>First Name: (*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="text" class="form-control" id="state-warning"  required name="patient_first_name" value="{{ Patient.first_name }}" />
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa fa-user"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-5">
                                                                <div class="p-20">
                                                                    <h5><b> Last Name: (*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="text" name="patient_last_name" required class="form-control" id="state-warning" placeholder="Enter Last Name" value="{{ Patient.last_name }}">
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa fa-user"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>DOB: mm/dd/yy (*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                         <input type="text" class="form-control" name="patient_dob" data-date-format="mm/dd/yyyy" placeholder="Enter patient Date of Birth " id="datepicker-autoclose" value="{{ Patient.dob |date:"m/d/Y" }}">
                                                                         <span class="input-group-addon bg-custom b-0 text-white"><i class="icon-calender"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-4">
                                                                <div class="p-20">
                                                                    <h5><b>Address:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                         <input type="text" name="patient_address" class="form-control" id="id_patient_address" placeholder="Enter Patient address" value="{{ Patient.address }}">
                                                                    <span class="input-group-addon bg-custom b-0 text-white"><i class="fa ion-map "></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                            <div class="col-lg-5">
                                                                <div class="p-20">
                                                                    <h5><b>Address 2:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                         <input type="text" name="patient_address2" class="form-control" id="id_patient_address2" placeholder="Enter Patient address" value="{{ Patient.address2 }}">
                                                                         <span class="input-group-addon bg-custom b-0 text-white"><i class="fa ion-map "></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                            <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>SSN:(*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                         <input type="text" class="form-control" maxlength="9" name="patient_ssn" id="exampleInputPassword1" placeholder="Enter patient SSN" value="{{ Patient.SSN_number }}">
                                                                     <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa-legal"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                            <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>Phone:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="tel" step="1" name="patient_phone" class="form-control" id="id_patient_phone" placeholder="Enter Patient Phone" value="{{ Patient.phone }}">
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa-phone"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>City:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                       <input type="text" name="patient_city" class="form-control" id="id_patient_city" placeholder="Enter City" value="{{ Patient.city }}">
                                                                       <span class="input-group-addon bg-custom b-0 text-white"><i class="fa ion-map"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>



                                                           <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>Zip Code:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <input type="text" name="patient_zipcode" class="form-control" id="exampleInputEmail1" placeholder="Zip Code" value="{{ Patient.zipcode }}">
                                                                        <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa-map-marker"></i></span>
                                                                    </div>
                                                                </div>
                                                           </div>

                                                           <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>State:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                        <select id="id_patient_state" name="patient_state" class="form-control select2" data-style="btn-white">
                                                                                {% if states %}
                                                                                   {% for item in states %}
                                                                                     <option value="{{ item.code }}" {% if item.code == Patient.state %} selected{% endif %}>{{ item.name }}</option>
                                                                                   {% endfor %}
                                                                                {% endif %}
                                                                           </select>
                                                                    </div>
                                                                </div>
                                                           </div>


                                                            <div class="col-lg-3">
                                                                <div class="p-20">
                                                                    <h5><b>Gender:(*)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                          <select id="id_patient_gender" required name="patient_gender" class="form-control select2" data-style="btn-white">
                                                                              <option value=""> Select Patient Gender</option>
                                                                              <option value="M" {% if Patient.gender == 'M' %} selected{% endif %}> Male</option>
                                                                              <option value="F" {% if Patient.gender == 'F'%} selected{% endif %}> Female</option>
                                                                           </select>
                                                                     </div>
                                                                </div>
                                                            </div>

                                                            <div class="col-lg-4">
                                                                <div class="p-20">
                                                                    <h5><b>Ethnicity:</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                          <select id="id_patient_ethnicity" name="patient_ethnicity" class="form-control select2" data-style="btn-white">
                                                                              <option value="0"> Select Patient Ethnicty</option>
                                                                              <option value="1" {% if Patient.ethnicity == '1' %} selected{% endif %}> American Indian or Alaska Native</option>
                                                                              <option value="2" {% if Patient.ethnicity == '2' %} selected{% endif %}> Asian</option>
                                                                              <option value="3" {% if Patient.ethnicity == '3' %} selected{% endif %}> Black or African American</option>
                                                                              <option value="4" {% if Patient.ethnicity == '4' %} selected{% endif %}> Hispanic or Latino</option>
                                                                              <option value="5" {% if Patient.ethnicity == '5' %} selected{% endif %}> Native Hawaiian or Other Pacific Islander </option>
                                                                              <option value="6" {% if Patient.ethnicity == '6' %} selected{% endif %}> White</option>
                                                                              <option value="7" {% if Patient.ethnicity == '7' %} selected{% endif %}> Other</option>
                                                                           </select>
                                                                    </div>
                                                                </div>
                                                            </div>



                                                          <div class="col-lg-12">
                                                        <div class="form-group ">
                                                            <p class="control-label"><strong>Enter payor information</strong></p>

                                                                <div class="radio radio-custom radio-inline">
                                                                    <input type="radio" id="inlineRadio1" value="0" onclick="toggle(this)" name="billing_option" checked>
                                                                    <label for="inlineRadio1"> Client </label>
                                                                </div>

                                                                <div class="radio radio-custom radio-inline">
                                                                    <input type="radio" id="inlineRadio2" value="1" onclick="toggle(this)" name="billing_option">
                                                                    <label for="inlineRadio2"> Insurance </label>
                                                                </div>

                                                            <div id="uno" style="display:none">
                                                                <p class="text-muted font-13 m-b-15 m-t-20">Insurance Options:.</p>
                                                                <div class="col-sm-12">
                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio3" value="Medicare" name="insurance_name" checked>
                                                                        <label for="inlineRadio3"> Medicare </label>
                                                                    </div>

                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio4" value="Medicaid" name="insurance_name">
                                                                        <label for="inlineRadio4"> Medicaid </label>
                                                                    </div>

                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio5" value="Blue" name="insurance_name">
                                                                        <label for="inlineRadio5"> Blue Shield </label>
                                                                    </div>

                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio6" value="Other"  name="insurance_name">
                                                                        <label for="inlineRadio6"> Other </label>
                                                                    </div>
                                                                </div>
                                                                <div class="col-sm-12">

                                                                    <div class="col-lg-3">
                                                                        <div class="p-1">
                                                                            <h5><b>Subscriber No.</b></h5>
                                                                            <div class="input-group m-t-15">
                                                                                <input type="text" name="insurance_suscriber_number" class="form-control" id="exampleInputEmail1" value="">
                                                                                <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa-sort-numeric-asc"></i></span>
                                                                            </div>
                                                                        </div>
                                                                    </div>

                                                                    <div class="col-lg-3">
                                                                        <div class="p-1">
                                                                            <h5><b>DOB: mm/dd/yy (*)</b></h5>
                                                                            <div class="input-group m-t-15">
                                                                                 <input type="text" class="form-control" name="insurance__dob" data-date-format="mm/dd/yyyy" placeholder="Date of Birth " id="datepicker-autoclose" value="{{ Patient.dob |date:"m/d/Y" }}">
                                                                                 <span class="input-group-addon bg-custom b-0 text-white"><i class="icon-calender"></i></span>
                                                                            </div>
                                                                        </div>
                                                                   </div>

                                                                    <div class="col-lg-4">
                                                                        <div class="p-1">
                                                                            <h5><b>ICD9 Diagnosis Code:</b></h5>
                                                                            <div class="input-group m-t-15">
                                                                                  <select id="id_medicare_icd9" name="insurance_icd9" class="form-control select2" data-style="btn-white">
                                                                                        <option value="0"> Select ICD9 Diagnosis Code</option>
                                                                                        <option value="795.00">Nonspecific abnormal Papanicolaou smear of cervix - unspecified 795.00</option>
                                                                                        <option value="795.01">ASCUS favor benign 795.01</option>
                                                                                        <option value="795.02">ASCUS favor dysplasia 795.02</option>
                                                                                        <option value="795.09">Other nonspecific abnormal Papanicolaou smear of cervix 795.09</option>
                                                                                        <option value="627.3">Atrophic Vaginitis 627.3</option>
                                                                                        <option value="622.1">Dysplasia 622.1</option>
                                                                                        <option value="626.6">Metrorrhagia 626.6</option>
                                                                                        <option value="V22.0/V22.2">Pregnancy State V22.0/V22.2</option>
                                                                                        <option value="V24.2">Routine  Postpartum Follow Up V24.2</option>
                                                                                        <option value="616.10">Vaginitis 616.10</option>
                                                                                        <option value="627.2">Menopause 627.2</option>
                                                                                        <option value="616.0">Cervicitis 616.0</option>
                                                                                        <option value="V76.2" selected="selected">Routine V76.2</option>
                                                                                        <option value="S10.1">Oral Contraceptives-Eval Prior to Method S10.1</option>
                                                                                        <option value="S10.2">Oral Contraceptives-Maintain Adherence S10.2</option>
                                                                                        <option value="S20.1">Depo-Provera Injection-Eval prior to method S20.1</option>
                                                                                        <option value="S50.1">Barriers and spermicide-Eval prior to method S50.1</option>
                                                                                        <option value="S50.2">Barriers and spermicide-Maintain adherence S50.2</option>
                                                                                        <option value="">Other </option>
                                                                                   </select>
                                                                            </div>
                                                                        </div>
                                                                    </div>

                                                                    <div class="col-lg-2">
                                                                        <div class="p-1">
                                                                            <h5><b>UPIN:</b></h5>
                                                                            <div class="input-group m-t-15">
                                                                                <input type="text" name="insurance_upin" class="form-control" id="exampleInputEmail1" placeholder="UPIN" value="">
                                                                                <span class="input-group-addon bg-custom b-0 text-white"><i class="fa fa-map-marker"></i></span>
                                                                            </div>
                                                                        </div>
                                                                    </div>
                                                                </div>



                                                            </div>
                                                        </div>

                                                    </div>
                                                    <div class="col-lg-12">
                                                        <div class="col-lg-6">
                                                                <div class="p-1">
                                                                    <h5><b>Responsible Party (if different from patient)</b></h5>
                                                                    <div class="input-group m-t-15">
                                                                         <input type="text" name="responsible_party" class="form-control" id="id_patient_address2"  value="">
                                                                         <span class="input-group-addon bg-custom b-0 text-white"><i class="fa ion-map "></i></span>
                                                                    </div>
                                                                </div>
                                                        </div>

                                                        <div class="col-lg-6">
                                                            <p class="text-muted font-13 m-b-15 m-t-20">Relationship To Patient:</p>
                                                                <div class="col-sm-12">
                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio7" value="Self" name="insurance_relationship" checked>
                                                                        <label for="inlineRadio7"> Self </label>
                                                                    </div>

                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio8" value="Child" name="insurance_relationship">
                                                                        <label for="inlineRadio8"> Child </label>
                                                                    </div>

                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio9" value="Spouse" name="insurance_relationship">
                                                                        <label for="inlineRadio9"> Spouse </label>
                                                                    </div>

                                                                    <div class="radio radio-custom radio-inline">
                                                                        <input type="radio" id="inlineRadio10" value="Other"  name="insurance_relationship">
                                                                        <label for="inlineRadio10"> Other </label>
                                                                    </div>
                                                                </div>
                                                        </div>




                                                    </div>


                                                    </div>


                                                {% endif %}

                                            </section>
                                            <h3>Test Information</h3>
                                            <section>
                                                <div>
                                                   <div class="col-lg-4">
                                                        <select class="selectpicker" multiple data-style="btn-white">
                                                            <option>Mustard</option>
                                                            <option>Ketchup</option>
                                                            <option>Relish</option>
                                                        </select>
                                                       </div>


                                                      <h5 class="m-t-30"><b>Multiple Select</b></h5>

											<select class="select2" select2-multiple multiple="multiple" multiple data-placeholder="Choose ...">
		                                        <optgroup label="Alaskan/Hawaiian Time Zone">
		                                            <option value="AK">Alaska</option>
		                                            <option value="HI">Hawaii</option>
		                                        </optgroup>
		                                        <optgroup label="Pacific Time Zone">
		                                            <option value="CA">California</option>
		                                            <option value="NV">Nevada</option>
		                                            <option value="OR">Oregon</option>
		                                            <option value="WA">Washington</option>
		                                        </optgroup>
		                                        <optgroup label="Mountain Time Zone">
		                                            <option value="AZ">Arizona</option>
		                                            <option value="CO">Colorado</option>
		                                            <option value="ID">Idaho</option>
		                                            <option value="MT">Montana</option>
		                                            <option value="NE">Nebraska</option>
		                                            <option value="NM">New Mexico</option>
		                                            <option value="ND">North Dakota</option>
		                                            <option value="UT">Utah</option>
		                                            <option value="WY">Wyoming</option>
		                                        </optgroup>
		                                        <optgroup label="Central Time Zone">
		                                            <option value="AL">Alabama</option>
		                                            <option value="AR">Arkansas</option>
		                                            <option value="IL">Illinois</option>
		                                            <option value="IA">Iowa</option>
		                                            <option value="KS">Kansas</option>
		                                            <option value="KY">Kentucky</option>
		                                            <option value="LA">Louisiana</option>
		                                            <option value="MN">Minnesota</option>
		                                            <option value="MS">Mississippi</option>
		                                            <option value="MO">Missouri</option>
		                                            <option value="OK">Oklahoma</option>
		                                            <option value="SD">South Dakota</option>
		                                            <option value="TX">Texas</option>
		                                            <option value="TN">Tennessee</option>
		                                            <option value="WI">Wisconsin</option>
		                                        </optgroup>
		                                        <optgroup label="Eastern Time Zone">
		                                            <option value="CT">Connecticut</option>
		                                            <option value="DE">Delaware</option>
		                                            <option value="FL">Florida</option>
		                                            <option value="GA">Georgia</option>
		                                            <option value="IN">Indiana</option>
		                                            <option value="ME">Maine</option>
		                                            <option value="MD">Maryland</option>
		                                            <option value="MA">Massachusetts</option>
		                                            <option value="MI">Michigan</option>
		                                            <option value="NH">New Hampshire</option>
		                                            <option value="NJ">New Jersey</option>
		                                            <option value="NY">New York</option>
		                                            <option value="NC">North Carolina</option>
		                                            <option value="OH">Ohio</option>
		                                            <option value="PA">Pennsylvania</option>
		                                            <option value="RI">Rhode Island</option>
		                                            <option value="SC">South Carolina</option>
		                                            <option value="VT">Vermont</option>
		                                            <option value="VA">Virginia</option>
		                                            <option value="WV">West Virginia</option>
		                                        </optgroup>
		                                    </select>



                                                </div>

                                            </section>
                                            <h3>Confirmation</h3>
                                            <section>
                                                <div class="form-group clearfix">
                                                    <div class="col-lg-12">
                                                        <p class="text-muted font-13 m-b-15 m-t-20">Specimen Source:</p>
                                                        <div class="checkbox checkbox-custom checkbox-inline">
                                                            <input type="checkbox" id="inlineCheckbox1" name="specimen_source_cervix" value="Cervix" checked>
                                                            <label for="inlineCheckbox1"> Cervix  </label>
                                                        </div>
                                                        <div class="checkbox checkbox-custom checkbox-inline">
                                                            <input type="checkbox" id="inlineCheckbox2" value="Vaginal" name="specimen_source_vaginal" checked>
                                                            <label for="inlineCheckbox2"> Vaginal </label>
                                                        </div>
                                                        <div class="checkbox checkbox-custom checkbox-inline">
                                                            <input type="checkbox" id="inlineCheckbox3" value="Endocervix" name="specimen_source_endocervix">
                                                            <label for="inlineCheckbox3"> Endocervix </label>
                                                        </div>
                                                        <div class="checkbox checkbox-custom checkbox-inline">
                                                            <input type="checkbox" id="inlineCheckbox4" value="None" name="specimen_source_none">
                                                            <label for="inlineCheckbox4"> None given </label>
                                                        </div>
                                                    </div>
                                                    <div class="col-lg-12">
                                                        <p class="text-muted font-13 m-b-15 m-t-20">Specimen Type:</p>

                                                        <div class="radio radio-custom radio-inline">
                                                            <input type="radio" id="inlineRadio11" value="1" onclick="toggle2(this)" name="specimen_type" checked>
                                                            <label for="inlineRadio11"> Liquid Based (Thin-prep) </label>
                                                        </div>

                                                        <div class="radio radio-custom radio-inline">
                                                            <input type="radio" id="inlineRadio12" value="0" onclick="toggle2(this)" checked  name="specimen_type">
                                                            <label for="inlineRadio12"> Conventional |  </label>
                                                        </div>

                                                        <div class="checkbox checkbox-custom checkbox-inline">
                                                            <input type="checkbox" id="inlineCheckbox5" value="None" name="pap_smear">
                                                            <label for="inlineCheckbox5"> Pap Smear with Hormonal Evaluation </label>
                                                        </div>

                                                    </div>

                                                    <div id="dos" style="display:none">
                                                        <p class="text-muted font-13 m-b-15 m-t-20">Additional Request (For Liquid Based Specimen):</p>
                                                            <div class="col-sm-12">
                                                                <div class="checkbox checkbox-custom checkbox-inline">
                                                                <input type="checkbox" id="inlineCheckbox6" name="aditional_hight_risk" value="hight_risk">
                                                                <label for="inlineCheckbox6"> High Risk HPV Test </label>
                                                            </div>

                                                            <div class="checkbox checkbox-custom checkbox-inline">
                                                                <input type="checkbox" id="inlineCheckbox7" name="aditional_maturation" value="req_maturation">
                                                                <label for="inlineCheckbox7"> Request Maturation Index (vaginal smear only) </label>
                                                            </div>

                                                            <div class="checkbox checkbox-custom checkbox-inline">
                                                                <input type="checkbox" id="inlineCheckbox8" name="aditional_gonorrhea" value="gonorrhea">
                                                                <label for="inlineCheckbox8"> Gonorrhea  </label>
                                                            </div>

                                                            <div class="checkbox checkbox-custom checkbox-inline">
                                                                <input type="checkbox" id="inlineCheckbox9" name="aditional_chlamydia" value="chlamydia">
                                                                <label for="inlineCheckbox9"> Chlamydia  </label>
                                                            </div>

                                                        </div>
                                                    </div>


                                                </div>
                                            </section>
                                            <h3>Confirm</h3>
                                            <section>
                                                <div class="form-group clearfix">
                                                    <div class="col-lg-12">
                                                        <div class="checkbox checkbox-primary">
                                                            <input id="checkbox-h" type="checkbox">
                                                            <label for="checkbox-h">
                                                                I agree with the Terms and Conditions.
                                                            </label>
                                                        </div>
                                                    </div>
                                                </div>
                                            </section>

                                        </div>
                                    </form>


                                {% if not Patient %}
                                        <div id="con-close-modal" class="modal fade" tabindex="-1" role="dialog" aria-labelledby="myModalLabel" aria-hidden="true" style="display: none;">
                                        <div class="modal-dialog">
                                            <div class="modal-content">
                                                <div class="modal-header">
                                                    <button type="button" class="close" data-dismiss="modal" aria-hidden="true">×</button>
                                                    <h4 class="modal-title">Modal Content is Responsive</h4>
                                                </div>
                                                <div class="modal-body">
                                                    <div class="row">
                                                        <div class="col-md-6">
                                                            <div class="form-group">
                                                                <label for="field-1" class="control-label">Name</label>
                                                                <input type="text" class="form-control" id="field-1" placeholder="John">
                                                            </div>
                                                        </div>
                                                        <div class="col-md-6">
                                                            <div class="form-group">
                                                                <label for="field-2" class="control-label">Surname</label>
                                                                <input type="text" class="form-control" id="field-2" placeholder="Doe">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-md-12">
                                                            <div class="form-group">
                                                                <label for="field-3" class="control-label">Address</label>
                                                                <input type="text" class="form-control" id="field-3" placeholder="Address">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-md-4">
                                                            <div class="form-group">
                                                                <label for="field-4" class="control-label">City</label>
                                                                <input type="text" class="form-control" id="field-4" placeholder="Boston">
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4">
                                                            <div class="form-group">
                                                                <label for="field-5" class="control-label">Country</label>
                                                                <input type="text" class="form-control" id="field-5" placeholder="United States">
                                                            </div>
                                                        </div>
                                                        <div class="col-md-4">
                                                            <div class="form-group">
                                                                <label for="field-6" class="control-label">Zip</label>
                                                                <input type="text" class="form-control" id="field-6" placeholder="123456">
                                                            </div>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-md-12">
                                                            <div class="form-group no-margin">
                                                                <label for="field-7" class="control-label">Personal Info</label>
                                                                <textarea class="form-control autogrow" id="field-7" placeholder="Write something about yourself" style="overflow: hidden; word-wrap: break-word; resize: horizontal; height: 104px;"></textarea>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="modal-footer">
                                                    <button type="button" class="btn btn-default waves-effect" data-dismiss="modal">Close</button>
                                                    <button type="button" class="btn btn-info waves-effect waves-light">Save changes</button>
                                                </div>
                                            </div>
                                        </div>
                                    </div><!-- /.modal -->

                                {% endif %}


                            	</div>


                            <!-- End row -->

                            </div> <!-- end col -->
                        </div>

						<!-- end row -->



                    </div> <!-- container -->

                </div> <!-- content -->




{% endblock %}