39 lines
1.8 KiB
PHP
39 lines
1.8 KiB
PHP
<div class="modal fade" tabindex="-1" role="dialog" id="create_modal">
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<div class="modal-dialog modal-dialog-centered" role="document">
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<div class="modal-content">
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<div class="modal-header">
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<h5 class="modal-title">Tambah Data</h5>
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<button type="button" class="close" data-dismiss="modal" aria-label="Close">
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<span aria-hidden="true">×</span>
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</button>
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</div>
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<form action="/registrasi" method="post" id="create_data_form">
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@csrf
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<div class="modal-body">
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<div class="form-group">
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<label for="exampleInputEmail1">Nama Pasien</label>
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<select name="pasien_uid" id="pasien_uid" style="width: 100%;" required></select>
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</div>
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<div class="form-group">
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<label for="exampleInputEmail1">Asuransi</label>
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<select name="asuransi_uid" id="asuransi_uid" style="width: 100%;" required></select>
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</div>
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<div class="form-group">
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<label for="exampleInputEmail1">No Kartu Asuransi</label>
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<input type="text" class="form-control" name="no_card_asuransi" required>
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</div>
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<div class="form-group">
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<label for="exampleInputEmail1">Ruang Pelayanan</label>
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<select name="ruang_pelayanan_uid" id="ruang_pelayanan_uid" style="width: 100%;" required></select>
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</div>
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</div>
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<div class="modal-footer bg-whitesmoke br">
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<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
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<button type="submit" class="btn btn-primary">Save changes</button>
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</div>
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</form>
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</div>
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</div>
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</div>
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