82 lines
4.7 KiB
PHP
Executable File
82 lines
4.7 KiB
PHP
Executable File
<?php $this->titre = "INTER-SANTE - Consulter une approbation de substitution Pharmacie"; ?>
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<form >
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<INPUT class="sr-only" TYPE="text" id="idDemandesubstitution" name="idDemandesubstitution" value="<?= $this->nettoyer($ententeprealable['idDemandesubstitution']) ?>">
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<INPUT class="sr-only" TYPE="text" id="prestataire" name="prestataire" value="<?= $this->nettoyer($ententeprealable['prestataire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="beneficiaire" name="beneficiaire" value="<?= $this->nettoyer($ententeprealable['beneficiaire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="numeroBeneficiaire" name="numeroBeneficiaire" value="<?= $this->nettoyer($ententeprealable['numeroBeneficiaire']) ?>">
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<INPUT class="sr-only" TYPE="text" id="nomPrescrit" name="nomPrescrit" value="<?= $this->nettoyer($ententeprealable['nomPrescrit']) ?>">
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<INPUT class="sr-only" TYPE="text" id="libelleSubstitut" name="libelleSubstitut" value="<?= $this->nettoyer($ententeprealable['libelleSubstitut']) ?>">
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<legend> <?= _("Consulter une demande d'approbation de substitution de médicament Pharmacie") ?> </legend>
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<table class="table table-responsive table-condensed" style='font-size:10pt;'>
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<tbody>
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<tr>
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<td width="10%" > <?= _("No") ?> </td>
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<td width="20%"> <INPUT id="numeroDemandeSubstitution" name="numeroDemandeSubstitution" class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['numeroDemandeSubstitution']) ?>" readonly> </td>
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<td width="10%" align="center"> <?= _("Prescrit") ?> </td>
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<td colspan="3"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['nomPrescrit']) ?>" readonly> </td>
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</tr>
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<tr>
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<td width="10%" > <?= _("Police") ?> </td>
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<td width="20%"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['libellePolice']) ?>" readonly> </td>
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<td width="10%" align="center"> <?= _("Substitut") ?> </td>
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<td colspan="3"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['libelleSubstitut']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> Date </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= dateheureLang($this->nettoyer($ententeprealable['dateSysteme'])) ?>" readonly> </td>
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<td align="center"> <?= _("Prestataire") ?> </td>
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<td colspan="3"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['prestataire']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Bénéficiaire") ?> </td>
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<td colspan="5"><INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['beneficiaire']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Répondu le") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= dateheureLang($this->nettoyer($ententeprealable['dateReponse'])) ?>" readonly> </td>
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<td align="center"> <?= _("Réponse") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['reponsentEnteprealable']) ?>" readonly> </td>
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<td align="center"> <?= _("Par") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['responsableAccord']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Motif Réel") ?> </td>
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<td colspan="5"><INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['motifReel']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Motif Assuré") ?> </td>
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<td colspan="5"><INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['motifRefusAssure']) ?>" readonly> </td>
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</tr>
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<tr>
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<td> <?= _("Prix prescrit") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= format_N($this->nettoyer($ententeprealable['prixPrescription'])) ?>" readonly> </td>
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<td align="center"> <?= _("Prix substitut") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= format_N($this->nettoyer($ententeprealable['prixSubstitution'])) ?>" readonly> </td>
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<td align="center" > <?= _("GAP") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['gap']) ?>" readonly> </td>
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</tr>
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</tbody>
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</table>
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</form>
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<div id ="div_wait">
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</div>
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