169 lines
8.8 KiB
PHP
169 lines
8.8 KiB
PHP
@extends('layouts.app')
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@section('content')
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<div class="container">
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<h2 class="text-center mb-4">Registrasi Pasien Baru</h1>
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@if (session('success'))
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<div class="alert alert-success alert-dismissible fade show" role="alert">
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<strong>Success!</strong> {{ session('success') }}
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<button type="button" class="close" data-dismiss="alert" 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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@endif
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@if ($errors->any())
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<div class="alert alert-danger">
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<ul>
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@foreach ($errors->all() as $error)
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<li>{{ $error }}</li>
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@endforeach
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</ul>
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</div>
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@endif
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<form method="POST" action="{{ route('registrasi.store') }}">
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@csrf
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<!-- Data Pasien Section -->
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<div class="card mb-4 shadow-sm">
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<div class="card-header bg-primary text-white">
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<h5 class="mb-0">Data Pasien</h5>
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</div>
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<div class="card-body">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="nik">NIK *</label>
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<input type="text" name="nik" class="form-control" id="nik"
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value="{{ old('nik') }}" required>
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="nama_pasien">Nama Pasien *</label>
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<input type="text" name="nama_pasien" class="form-control" id="nama_pasien"
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value="{{ old('nama_pasien') }}" required>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-4">
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<div class="form-group">
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<label for="jenis_kelamin">Jenis Kelamin *</label>
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<select name="jenis_kelamin" id="jenis_kelamin" class="form-control" required>
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<option value="Laki-Laki"
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{{ old('jenis_kelamin') == 'Laki-Laki' ? 'selected' : '' }}>
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Laki-Laki</option>
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<option value="Perempuan"
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{{ old('jenis_kelamin') == 'Perempuan' ? 'selected' : '' }}>
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Perempuan</option>
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</select>
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="tanggal_lahir">Tanggal Lahir *</label>
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<input type="date" name="tanggal_lahir" class="form-control" id="tanggal_lahir"
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value="{{ old('tanggal_lahir') }}" required>
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</div>
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</div>
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<div class="col-md-4">
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<div class="form-group">
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<label for="nomor_telepon">Nomor Telepon</label>
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<input type="text" name="nomor_telepon" class="form-control" id="nomor_telepon"
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value="{{ old('nomor_telepon') }}">
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</div>
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</div>
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</div>
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</div>
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</div>
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<!-- Data Registrasi Section -->
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<div class="card mb-4 shadow-sm">
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<div class="card-header bg-primary text-white">
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<h5 class="mb-0">Data Registrasi</h5>
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</div>
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<div class="card-body">
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="pegawai_id">Dokter/Pegawai *</label>
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<select name="pegawai_id" id="pegawai_id" class="form-control" required>
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@foreach ($pegawai as $p)
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<option value="{{ $p->id }}"
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{{ old('pegawai_id') == $p->id ? 'selected' : '' }}>
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{{ $p->nama_pegawai }}
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</option>
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@endforeach
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</select>
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="ruang_pelayanan_id">Ruang Pelayanan *</label>
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<select name="ruang_pelayanan_id" id="ruang_pelayanan_id" class="form-control" required>
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@foreach ($ruang_pelayanan as $r)
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<option value="{{ $r->id }}"
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{{ old('ruang_pelayanan_id') == $r->id ? 'selected' : '' }}>
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{{ $r->nama_ruang_pelayanan }}
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</option>
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@endforeach
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</select>
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="asuransi_id">Asuransi</label>
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<select name="asuransi_id" id="asuransi_id" class="form-control">
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@foreach ($asuransi as $a)
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<option value="{{ $a->id }}"
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{{ old('asuransi_id') == $a->id ? 'selected' : '' }}>
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{{ $a->nama_asuransi }}
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</option>
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@endforeach
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</select>
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="nomor_kartu_asuransi">Nomor Kartu Asuransi</label>
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<input type="text" name="nomor_kartu_asuransi" class="form-control"
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id="nomor_kartu_asuransi" value="{{ old('nomor_kartu_asuransi') }}">
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</div>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6">
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<div class="form-group">
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<label for="tanggal_registrasi">Tanggal Registrasi *</label>
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<input type="date" name="tanggal_registrasi" class="form-control"
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id="tanggal_registrasi" value="{{ old('tanggal_registrasi', date('Y-m-d')) }}"
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required>
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</div>
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</div>
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<div class="col-md-6">
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<div class="form-group">
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<label for="keluhan">Keluhan</label>
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<textarea name="keluhan" id="keluhan" class="form-control">{{ old('keluhan') }}</textarea>
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</div>
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</div>
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</div>
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</div>
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</div>
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<div class="text-center">
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<button type="submit" class="btn btn-success btn-lg">
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<i class="fas fa-save"></i> Simpan Registrasi
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</button>
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</div>
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</form>
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</div>
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@endsection
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