65 lines
4.2 KiB
PHP
65 lines
4.2 KiB
PHP
<x-app-layout>
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<div class="py-12">
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<div class="max-w-3xl mx-auto sm:px-6 lg:px-8">
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<div class="bg-white overflow-hidden shadow-sm sm:rounded-lg">
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<div class="p-6 bg-white border-b border-gray-200">
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{{-- Back button --}}
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<h1 class="text-xl mb-4 font-bold">Pendaftaran Pelayanan</h1>
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<form action="{{ route('admin.tr_registrasi.store') }}" method="POST">
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@csrf
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<div class="mb-4">
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<label class="block font-medium text-sm mb-2">Pasien<span class="text-red-600">*</span></label>
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<select name="mr_pasien" required class="text-sm block mt-1 w-full p-2 bg-gray-50 border border-gray-300 focus:ring-gray-500 focus:border-gray-500 rounded-md shadow-sm placeholder-gray-300">
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<option value="">-- Pilih --</option>
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@foreach ($pasien as $p)
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<option value="{{ $p->mr_pasien }}">{{ $p->nama_pasien .' - '. $p->mr_pasien}}</option>
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@endforeach
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</select>
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</div>
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<div class="mb-4">
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<label class="block font-medium text-sm mb-2">Asuransi<span class="text-red-600">*</span></label>
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<select name="id_asuransi" required class="text-sm block mt-1 w-full p-2 bg-gray-50 border border-gray-300 focus:ring-gray-500 focus:border-gray-500 rounded-md shadow-sm placeholder-gray-300">
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<option value="">-- Pilih --</option>
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@foreach ($asuransi as $a)
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<option value="{{ $a->id_asuransi }}">{{ $a->nama_asuransi }}</option>
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@endforeach
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</select>
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</div>
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<x-input id="no_asuransi" label="No. Asuransi" name="no_asuransi" placeholder="misal: Budi" required />
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<div class="mb-4">
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<label class="block font-medium text-sm mb-2">Ruang Pelayanan<span class="text-red-600">*</span></label>
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<select name="id_ruang_pelayanan" required class="text-sm block mt-1 w-full p-2 bg-gray-50 border border-gray-300 focus:ring-gray-500 focus:border-gray-500 rounded-md shadow-sm placeholder-gray-300">
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<option value="">-- Pilih --</option>
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@foreach ($ruang_pelayanan as $rp)
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<option value="{{ $rp->id_ruang_pelayanan }}">{{ $rp->id_ruang_pelayanan . ' - ' . $rp->nama_ruang_pelayanan }}</option>
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@endforeach
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</select>
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</div>
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<div class="mb-4">
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<label class="block font-medium text-sm mb-2">Pegawai<span class="text-red-600">*</span></label>
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<select name="id_pegawai" required class="text-sm block mt-1 w-full p-2 bg-gray-50 border border-gray-300 focus:ring-gray-500 focus:border-gray-500 rounded-md shadow-sm placeholder-gray-300">
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<option value="">-- Pilih --</option>
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@foreach ($pegawai as $pg)
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<option value="{{ $pg->id_pegawai }}">{{ $pg->nama_pegawai }}</option>
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@endforeach
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</select>
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</div>
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{{-- Submit button --}}
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<div class="flex justify-end mt-4">
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<a href="{{ route('admin.tr_registrasi.index') }}" class="bg-gray-300 text-gray-700 px-4 py-2 rounded-md mr-2">Batal</a>
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<button type="submit" class="bg-blue-500 text-white px-4 py-2 rounded-md">Simpan Perubahan</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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</div>
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</x-app-layout>
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