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

{% block content %}

            <!-- ============================================================== -->
            <!-- Start right Content here -->
            <!-- ============================================================== -->
            <div class="content-page">
                <!-- 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">
                                        {% csrf_token %}
                                        <div>
                                            <h3>Patient Info</h3>
                                            <section>
                                                <div class="col-lg-3">

                                                    <div class="form-group">
                                                            <label for="exampleInputEmail1" >Collection Date: mm/dd/yyyy (*)</label>
                                                            <input type="text" required name="collection_date" id="state-warning" class="form-control" data-date-format="mm/dd/yyyy" placeholder="Enter Collection Date" id="datepicker-autoclose">
                                                           <!--<span class="input-group-addon bg-custom b-0 text-white"><i class="icon-calender"></i></span> -->
                                                    </div>

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Patient ID# (*)</label>
	                                                    <input type="text" required name="patient_id" class="form-control" id="state-warning"  placeholder="Enter Patient ID">
                                                    </div>

                                                    <div class="form-group">
                                                        <label for="exampleInputPassword1">Attending Physician Name:</label>
                                                        <input type="text" name="physician_name" class="form-control" id="state-warning"  placeholder="Enter Physician Name:">
                                                    </div>

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Physician/Business Name: (*)</label>
	                                                    <input type="text" required class="form-control" id="exampleInputEmail1" placeholder="Physician/Business Name:">
                                                    </div>

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Address</label>
	                                                    <input type="text" name="patient_address" class="form-control" id="exampleInputEmail1" placeholder="Enter pattient address">
                                                    </div>



                                                </div>

                                                <div class="col-lg-3">

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Last Name:(*)</label>
	                                                    <input type="text" name="patient_last_name" required class="form-control" id="exampleInputEmail1" placeholder="Enter email">
                                                    </div>

                                                    <div class="form-group">
                                                         <label  for="exampleInputPhone" >Gender:(*)</label>
                                                              <select id="id_patient_gender" required name="patient_gender" class="form-control">
                                                                  <option value=""> Select Patient Gender</option>
                                                                  <option value="M"> Male</option>
                                                                  <option value="F"> Female</option>
                                                               </select>
                                                    </div>

                                                    <div class="form-group">
                                                        <label for="exampleInputPhone" >City:</label>
                                                        <input type="text" name="patient_city" class="form-control" id="id_patient_city" placeholder="Enter your City">
                                                    </div>

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Address 2:</label>
	                                                    <input type="text" name="patient_address" class="form-control" id="exampleInputEmail1" placeholder="Enter pattient address">
                                                    </div>



                                                </div>

                                                <div class="col-lg-3">

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">First Name:(*)</label>
	                                                    <input type="text" required name="patient_first_name" class="form-control" id="exampleInputEmail1" placeholder="Enter email">
                                                    </div>

                                                    <div class="form-group">
                                                        <label for="exampleInputPassword1">SSN:</label>
                                                        <input type="text" class="form-control" id="exampleInputPassword1" placeholder="Enter patient SSN">
                                                    </div>

                                                    <div class="form-group">
                                                         <label  style="float:left" for="exampleInputPhone" >Ethnicity:</label>
                                                              <select id="id_patient_ethnicity" name="patient_ethnicity" class="form-control">
                                                                  <option value="0"> Select Patient Ethnicty</option>
                                                                  <option value="1"> American Indian or Alaska Native</option>
                                                                  <option value="2"> Asian</option>
                                                                  <option value="3"> Black or African American</option>
                                                                  <option value="4"> Hispanic or Latino</option>
                                                                  <option value="5"> Native Hawaiian or Other Pacific Islander </option>
                                                                  <option value="6"> White</option>
                                                                  <option value="7"> Other</option>
                                                               </select>
                                                    </div>

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Zip Code</label>
	                                                    <input type="text" name="patient_zipcode" class="form-control" id="exampleInputEmail1" placeholder="Enter patient address">
                                                    </div>

                                                </div>

                                                <div class="col-lg-3">

                                                    <div class="form-group">
                                                            <label for="exampleInputEmail1" >DOB: mm/dd/yyyy (*)</label>
                                                            <input type="text" class="form-control" data-date-format="mm/dd/yyyy" placeholder="Enter patient Date of Birth " id="datepicker-autoclose">
                                                         <!--  <span class="input-group-addon bg-custom b-0 text-white"><i class="icon-calender"></i></span> -->
                                                    </div>

                                                    <div class="form-group">
                                                        <label for="exampleInputPassword1">Age:</label>
                                                        <input type="number" step="1" name="patient_age" class="form-control" id="exampleInputPassword1" placeholder="Enter patient Age">
                                                    </div>

                                                    <div class="form-group">
	                                                    <label for="exampleInputEmail1">Email address</label>
	                                                    <input type="text" class="form-control" id="exampleInputEmail1" placeholder="Enter email">
                                                    </div>

                                                    <div class="form-group">
                                                         <label for="exampleInputPhone" >State:</label>
                                                              <select id="id_patient_state" name="patient_state" class="form-control">
                                                                    {% if states %}
                                                                       {% for item in states %}
                                                                         <option value="{{ item.code }}"> {{ item.name }}</option>
                                                                       {% endfor %}
                                                                    {% endif %}
                                                               </select>
                                                    </div>

                                                </div>

                                                <div class="form-group clearfix">
                                                    <label class="col-lg-12 control-label ">(*) Mandatory</label>
                                                </div>

                                            </section>
                                            <h3>Billing Info</h3>
                                            <section>
                                                <div class="col-lg-3">

                                                </div>

                                                <div class="col-lg-3">

                                                </div>

                                                <div class="col-lg-3">

                                                </div>

                                                <div class="col-lg-3">

                                                </div>

                                                <div class="form-group clearfix">
                                                    <label class="col-lg-12 control-label ">(*) Mandatory</label>
                                                </div>

                                            </section>
                                            <h3>Request Test</h3>
                                            <section>
                                                <div class="form-group clearfix">
                                                    <div class="col-lg-12">
                                                        <ul class="list-unstyled w-list">
	                                                        <li><b>First Name :</b> Jonathan </li>
	                                                        <li><b>Last Name :</b> Smith </li>
	                                                        <li><b>Emial:</b> jonathan@smith.com</li>
	                                                        <li><b>Address:</b> 123 Your City, Cityname. </li>
	                                                    </ul>
                                                    </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>


                            	</div>


                            <!-- End row -->

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

						<!-- end row -->



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

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


{% endblock %}