374 lines
15 KiB
PHP
374 lines
15 KiB
PHP
<!DOCTYPE html>
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<html lang="id">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1.0">
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<title>Registrasi | SIM-RS Anak dan Bunda Harapan Kita</title>
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<link href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/6.4.0/css/all.min.css" rel="stylesheet">
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<link href="https://cdnjs.cloudflare.com/ajax/libs/bootstrap/5.3.0/css/bootstrap.min.css" rel="stylesheet">
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<style>
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:root {
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--primary-color: #0075c9;
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--secondary-color: #64c4ed;
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--accent-color: #ffaa00;
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--light-color: #f8fcff;
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--dark-color: #124467;
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}
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body {
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font-family: 'Nunito', sans-serif;
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background: linear-gradient(135deg, rgba(18, 68, 103, 0.95), rgba(0, 117, 201, 0.85)),
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url('https://images.unsplash.com/photo-1576091160550-2173dba999ef?ixlib=rb-4.0.3&auto=format&fit=crop&w=2070&q=80');
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background-size: cover;
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background-position: center;
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background-attachment: fixed;
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min-height: 100vh;
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display: flex;
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flex-direction: column;
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}
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.registration-container {
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flex: 1;
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padding: 40px 20px;
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}
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.registration-card {
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background-color: rgba(255, 255, 255, 0.95);
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border-radius: 20px;
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box-shadow: 0 15px 30px rgba(0, 0, 0, 0.2);
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overflow: hidden;
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position: relative;
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}
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.registration-card::before {
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content: '';
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position: absolute;
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top: 0;
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left: 0;
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width: 100%;
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height: 8px;
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background: linear-gradient(90deg, var(--primary-color), var(--secondary-color));
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}
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.hospital-logo {
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width: 80px;
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height: 80px;
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object-fit: contain;
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padding: 10px;
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background-color: white;
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border-radius: 50%;
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box-shadow: 0 5px 15px rgba(0, 0, 0, 0.1);
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margin-bottom: 15px;
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}
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.display-title {
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background: linear-gradient(90deg, var(--primary-color), var(--secondary-color));
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-webkit-background-clip: text;
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-webkit-text-fill-color: transparent;
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font-weight: 800;
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margin-bottom: 10px;
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}
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.subtitle {
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color: var(--dark-color);
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font-weight: 600;
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}
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.btn-primary-gradient {
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background: linear-gradient(45deg, var(--primary-color), var(--secondary-color));
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border: none;
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color: white;
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font-weight: 600;
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padding: 12px 25px;
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border-radius: 30px;
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box-shadow: 0 4px 10px rgba(0, 117, 201, 0.3);
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transition: all 0.3s ease;
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}
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.btn-primary-gradient:hover {
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transform: translateY(-3px);
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box-shadow: 0 6px 15px rgba(0, 117, 201, 0.4);
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color: white;
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}
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.btn-outline-custom {
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background: transparent;
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border: 2px solid var(--primary-color);
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color: var(--primary-color);
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font-weight: 600;
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padding: 10px 20px;
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border-radius: 30px;
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transition: all 0.3s ease;
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}
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.btn-outline-custom:hover {
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background-color: var(--primary-color);
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color: white;
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transform: translateY(-3px);
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box-shadow: 0 6px 15px rgba(0, 117, 201, 0.2);
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}
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.form-label {
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color: var(--dark-color);
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font-weight: 600;
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margin-bottom: 5px;
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}
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.form-control {
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border-radius: 10px;
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padding: 10px 15px;
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border: 1px solid #dde5ed;
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background-color: #f8fcff;
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transition: all 0.3s;
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}
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.form-control:focus {
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box-shadow: 0 0 0 3px rgba(0, 117, 201, 0.2);
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border-color: var(--primary-color);
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}
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.input-group-text {
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border-radius: 10px 0 0 10px;
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border: 1px solid #dde5ed;
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background-color: #f0f7ff;
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color: var(--primary-color);
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}
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.header-line {
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height: 1px;
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background: linear-gradient(90deg, rgba(18, 68, 103, 0.1), rgba(0, 117, 201, 0.3), rgba(18, 68, 103, 0.1));
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margin: 20px 0;
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}
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.footer {
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background-color: rgba(18, 68, 103, 0.95);
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padding: 15px 0;
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color: white;
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}
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.footer a {
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color: var(--secondary-color);
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text-decoration: none;
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transition: color 0.3s;
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}
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.footer a:hover {
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color: var(--accent-color);
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}
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.back-link {
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color: var(--primary-color);
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text-decoration: none;
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font-weight: 600;
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display: inline-flex;
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align-items: center;
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transition: all 0.3s;
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}
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.back-link:hover {
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color: var(--secondary-color);
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transform: translateX(-3px);
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}
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.form-text {
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color: #6c757d;
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}
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/* Password strength indicator */
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.password-strength {
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height: 5px;
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margin-top: 5px;
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border-radius: 5px;
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transition: all 0.3s;
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background-color: #e9ecef;
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}
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.strength-weak {
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width: 30%;
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background-color: #dc3545;
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}
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.strength-medium {
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width: 70%;
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background-color: #ffc107;
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}
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.strength-strong {
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width: 100%;
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background-color: #28a745;
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}
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.form-floating > .form-select,
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.form-floating > .form-control {
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padding-top: 2rem !important;
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padding-bottom: 0px !important;
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}
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</style>
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</head>
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<body>
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<div class="registration-container container py-4">
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<div class="row justify-content-center">
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<div class="col-lg-10 col-xl-8">
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<div class="text-start mb-3">
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<a href="/" class="back-link">
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<i class="fas fa-arrow-left me-2"></i> Kembali ke Beranda
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</a>
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</div>
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<div class="registration-card p-4 p-md-5 my-2 position-relative">
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<div class="text-center mb-4">
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<img src="{{ asset('assets/images/logo.png') }}" alt="Logo RS" class="hospital-logo">
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<h2 class="h3 display-title">REGISTRASI PASIEN</h2>
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<p class="subtitle">Sistem Informasi Manajemen RS Anak dan Bunda Harapan Kita</p>
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</div>
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<div class="header-line"></div>
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<form action="{{ route('registrasi') }}" method="POST" class="mt-4">
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@csrf
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<div class="row g-3">
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<!-- Data Pribadi -->
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<div class="col-12">
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<div class="d-flex align-items-center mb-3">
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<div class="bg-primary rounded-circle p-2 me-3">
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<i class="fas fa-user-injured text-white"></i>
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</div>
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<h5 class="text-primary fw-bold mb-0">Informasi Pasien</h5>
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</div>
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</div>
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<div class="col-md-12">
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<div class="form-floating mb-3">
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<input type="text" class="form-control" id="nama_lengkap" name="nama_lengkap" placeholder="Nama Lengkap" required>
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<label for="nama_lengkap"><i class="fas fa-user me-2 text-primary"></i>Nama Lengkap</label>
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<div class="form-text ps-4">Cari nama sesuai data pasien yang pernah didaftarkan</div>
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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-floating">
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<input type="date" class="form-control" id="tanggal_registrasi" name="tanggal_registrasi" required>
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<label for="tanggal_registrasi"><i class="fas fa-calendar-alt me-2 text-primary"></i>Tanggal Registrasi</label>
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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-floating">
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<select class="form-select" id="nama_pegawai" name="nama_pegawai" required>
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<option value="" selected disabled></option>
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<option value="1">Dr. Andi Wijaya</option>
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<option value="2">Dr. Siti Rahma</option>
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<option value="3">Ns. Budi Santoso</option>
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</select>
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<label for="nama_pegawai"><i class="fas fa-user-md me-2 text-primary"></i>Petugas Pendaftar</label>
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</div>
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</div>
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<!-- Informasi Asuransi -->
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<div class="col-12 mt-4">
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<div class="d-flex align-items-center mb-3">
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<div class="bg-primary rounded-circle p-2 me-3">
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<i class="fas fa-id-card-alt text-white"></i>
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</div>
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<h5 class="text-primary fw-bold mb-0">Informasi Asuransi</h5>
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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-floating">
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<select class="form-select" id="asuransi" name="asuransi" required>
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<option value="" selected disabled></option>
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<option value="bpjs">BPJS Kesehatan</option>
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<option value="mandiri">Asuransi Mandiri</option>
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<option value="umum">Pembayaran Mandiri</option>
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</select>
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<label for="asuransi"><i class="fas fa-hospital me-2 text-primary"></i>Jenis Asuransi</label>
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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-floating">
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<input type="text" class="form-control" id="nomor_asuransi" name="nomor_asuransi" placeholder="Nomor Asuransi" required>
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<label for="nomor_asuransi"><i class="fas fa-credit-card me-2 text-primary"></i>Nomor Asuransi</label>
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</div>
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</div>
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<!-- Ruang Pelayanan -->
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<div class="col-12 mt-4">
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<div class="d-flex align-items-center mb-3">
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<div class="bg-primary rounded-circle p-2 me-3">
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<i class="fas fa-procedures text-white"></i>
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</div>
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<h5 class="text-primary fw-bold mb-0">Ruang Pelayanan</h5>
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</div>
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</div>
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<div class="col-md-12">
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<div class="form-floating">
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<select class="form-select" id="ruang_pelayanan" name="ruang_pelayanan" required>
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<option value="" selected disabled></option>
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<option value="poli_anak">Poli Anak</option>
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<option value="poli_kandungan">Poli Kandungan</option>
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<option value="ugd">Unit Gawat Darurat</option>
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<option value="lab">Laboratorium</option>
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</select>
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<label for="ruang_pelayanan"><i class="fas fa-door-open me-2 text-primary"></i>Pilih Ruang Pelayanan</label>
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</div>
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</div>
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<div class="col-12 mt-4 text-center">
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<button type="submit" class="btn btn-primary-gradient px-5 py-3">
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<i class="fas fa-user-plus me-2"></i> DAFTARKAN PASIEN
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</button>
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</div>
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<div class="col-12 mt-3 text-center">
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<div class="alert alert-info py-2">
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<i class="fas fa-info-circle me-2"></i>Pasien baru? <a href="{{ route('pasien.index') }}" class="fw-bold text-decoration-none">Klik untuk menambah data pasien baru</a>
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</div>
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</div>
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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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</div>
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<!-- Footer -->
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<footer class="footer text-center py-3">
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<div class="container">
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<p class="mb-0">
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© 2025 RS Anak dan Bunda Harapan Kita |
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<a href="#">Kebijakan Privasi</a> |
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<a href="#">Kontak Kami</a>
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</p>
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</div>
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</footer>
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<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap/5.3.0/js/bootstrap.bundle.min.js"></script>
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<script>
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// Auto-format nomor asuransi
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document.getElementById('nomor_asuransi').addEventListener('input', function(e) {
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this.value = this.value.replace(/[^0-9]/g, '');
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});
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// Show/hide nomor asuransi berdasarkan jenis asuransi
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document.getElementById('asuransi').addEventListener('change', function(e) {
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const nomorAsuransi = document.getElementById('nomor_asuransi');
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if(this.value === 'umum') {
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nomorAsuransi.disabled = true;
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nomorAsuransi.required = false;
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nomorAsuransi.value = '';
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} else {
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nomorAsuransi.disabled = false;
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nomorAsuransi.required = true;
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}
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});
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// Date picker default ke hari ini
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document.getElementById('tanggal_registrasi').valueAsDate = new Date();
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</script>
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</body>
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</html> |