128 lines
7.6 KiB
PHP
128 lines
7.6 KiB
PHP
<div class="form-step active">
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<div class="row g-3 mb-4">
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<input type="hidden" name="cart_data" id="cart_data">
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<div class="col-md-6">
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<label for="exampleInputEmail1" class="form-label">Apakah Anda Seorang ?</label>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_customer" id="radio_karyawan" value="Karyawan RSAB Harapan Kita" required>
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<label class="form-check-label" for="radio_karyawan" >
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Karyawan RSAB Harapan Kita
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_customer" id="radio_kp" value="Keluarga Pasien / Penunggu Pasien" required>
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<label class="form-check-label" for="radio_kp">
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Keluarga Pasien / Penunggu Pasien
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_customer" id="radio_public" value="Masyarakat Umum" required>
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<label class="form-check-label" for="radio_public">
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Masyarakat Umum
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</label>
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</div>
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</div>
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<div class="col-md-6">
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<label for="exampleInputEmail1" class="form-label">Jenis Kelamin</label>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_kelamin" value="Laki-laki" required>
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<label class="form-check-label">
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Laki-laki
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="jenis_kelamin" id="radio_kp" value="Perempuan" required>
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<label class="form-check-label">
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Perempuan
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</label>
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</div>
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</div>
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<div class="col-md-6">
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<label class="form-label">Nama Pemesan</label>
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<input type="text" class="form-control" name="nama_pemesan" id="nama_pemesan" required>
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</div>
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<div class="col-md-6">
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<label class="form-label">No. Whatsapp</label>
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<input type="number" class="form-control" name="no_whatsapp" id="no_whatsapp" required>
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</div>
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<div class="col-md-12">
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<label class="form-label">Email</label>
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<input type="email" class="form-control" name="email" id="email" required>
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</div>
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{{-- <div class="col-md-6">
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<label class="form-label">Tanggal Lahir</label>
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<input type="date" class="form-control" name="tanggal_lahir" id="tanggal_lahir">
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</div> --}}
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<div class="col-md-6">
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<label class="form-label">Tinggi Badan</label>
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<input type="number" class="form-control" name="tinggi_badan" id="tinggi_badan">
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</div>
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<div class="col-md-6">
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<label class="form-label">Berat Badan</label>
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<input type="number" class="form-control" name="berat_badan" id="berat_badan">
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</div>
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{{-- Pasien --}}
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<div class="col-md-6 pasien">
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<label class="form-label">Nama Pasien</label>
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<input type="text" class="form-control pasien-field" name="nama_pasien" id="nama_pasien">
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</div>
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<div class="col-md-6 pasien">
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<label class="form-label">Ruang Perawatan</label>
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<select class="form-select pasien-field" name="ruang_perawatan" id="ruang_perawatan">
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<option value="">Pilih...</option>
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<option value="Ruang Kenanga">Ruang Kenanga</option>
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<option value="Ruang Menur">Ruang Menur</option>
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<option value="Ruang Melati">Ruang Melati</option>
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<option value="Ruang Mawar">Ruang Mawar</option>
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<option value="Ruang Cempaka">Ruang Cempaka</option>
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<option value="Ruang Widuri">Ruang Widuri</option>
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<option value="Ruang Teratai">Ruang Teratai</option>
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<option value="Klinik Anggrek">Klinik Melati</option>
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<option value="Ruang VK">Ruang VK</option>
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</select>
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</div>
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<div class="col-md-6 pasien">
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<label class="form-label">Nomor Kamar Perawatan</label>
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<input type="text" class="form-control pasien-field" name="no_kamar" id="no_kamar">
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</div>
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<div class="col-md-6 pasien">
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<label class="form-label">Kelas Perawatan </label>
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<select class="form-select pasien-field" name="kelas_perawatan" id="kelas_perawatan">
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<option value="">Pilih...</option>
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<option value="VIP A">VIP A</option>
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<option value="VIP B">VIP B</option>
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<option value="Kelas I">Kelas I</option>
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<option value="Mesa Tesa">Mesa Tesa</option>
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</select>
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</div>
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{{-- End Pasien --}}
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{{-- Karyawan --}}
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<div class="col-md-6 karyawan">
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<label class="form-label">Bagian /Instalasi</label>
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<input type="text" class="form-control karyawan-field" name="bagian_instalasi" id="bagian_instalasi">
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</div>
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<div class="col-md-6 karyawan">
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<label class="form-label">Ekstensien yang bisa di Hubungi</label>
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<input type="text" class="form-control karyawan-field" name="no_ekstensien" id="no_ekstensien">
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</div>
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{{-- End Karyawan --}}
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{{-- Umum --}}
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<div class="col-md-12 umum">
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<label class="form-label">Alamat</label>
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<textarea class="form-control umum-field" name="alamat" id="alamat"></textarea>
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</div>
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{{-- End Umum --}}
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</div>
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<button type="button" class="btn btn-success w-100 next-step">Lanjutkan</button>
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</div>
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