51 lines
2.1 KiB
PHP
Executable File
51 lines
2.1 KiB
PHP
Executable File
<?php
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$this->titre = "ISA WEB - Remboursement Hors Tiers Payant - Rechercher un assuré";
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?>
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<input class="sr-only" id="nomForm" name="nomForm" type="text" value= "remboursementClassic" >
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<input class="sr-only" type="text" id="idBeneficiaire" name="idBeneficiaire" value="<?= $idBeneficiaire ?>">
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<input class="sr-only" id="idAssure" name="idAssure" type="text" value="<?= $idBeneficiaire ;?>" >
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<div id="div_context_adherent">
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<input class="sr-only" id="aBeneficiaireRemb" name="aBeneficiaireRemb" type="text" value="<?= $aBeneficiaireRemb ;?>" >
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</div>
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<legend> <?= _("Rechercher un Assuré") ?></legend>
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<table class="table table-responsive" style='font-size:9pt;'>
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<tbody>
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<tr>
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<td width="8%" class="required"> <?= _("No Demandeur") ?> </td>
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<td >
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<div >
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<input id="searchInput" name="searchInput" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $numeroBeneficiaire ;?>" autofocus required AUTOCOMPLETE="OFF" AUTOCOMPLETE="OFF">
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<div id="div_selection" class="div_selection_list">
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</div>
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</div>
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</td>
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<td width="10%" align="center"> <?= _("Nom et Prénoms") ?> </td>
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<td colspan="2">
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<input id="nomAssure" name="nomAssure" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $beneficiaire ;?>" readonly>
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</td>
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<td width="5%" align="center"> <?= _("Lien") ?> </td>
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<td width="5%">
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<input id="codeLienParente" name="codeLienParente" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $codeLienParente ;?>" readonly>
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</td>
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</tr>
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<tr>
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<td > <?= _("No Adhérent") ?> </td>
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<td >
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<input id="noAdherent" name="noAdherent" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $noAdherent ;?>" readonly>
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</td>
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<td align="center"> <?= _("Adhérent") ?> </td>
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<td colspan="4">
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<input id="nomAdherent" name="nomAdherent" style="font-size:12pt; height:30px;" class="form-control" type="text" value="<?= $nomAdherent ;?>" readonly>
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</td>
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</tr>
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</tbody>
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</table>
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