79 lines
4.3 KiB
PHP
79 lines
4.3 KiB
PHP
<?php
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// $this->titre = "INTER-SANTE - Consulter une entente préalable Pharmmacie";
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$idBeneficiaire = $this->nettoyer($ententeprealable['idBeneficiaire']);
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?>
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<INPUT class="sr-only" TYPE="text" id="idDemandeententeprealable" name="idDemandeententeprealable" value="<?= $this->nettoyer($ententeprealable['idDemandeententeprealable']) ?>">
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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="libelleOptique" name="libelleOptique" value="<?= $this->nettoyer($ententeprealable['libelleOptique']) ?>">
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<legend> <?= _("Consulter une entente préalable Optique") ?> </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="numeroEntentePrealable" name="numeroEntentePrealable" class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['numeroEntentePrealable']) ?>" readonly> </td>
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<td width="10%" align="center"> <?= _("Acte") ?> </td>
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<td colspan="3"> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['libelleOptique']) ?>" 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> <?= _("Plafond") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= format_N($this->nettoyer($ententeprealable['plafond'])) ?>" readonly> </td>
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<td align="center"> <?= _("Solde") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= format_N($this->nettoyer($ententeprealable['soldeNew'])) ?>" readonly> </td>
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<td align="center" > <?= _("T M") ?> </td>
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<td> <INPUT class="form-control" TYPE="text" style='font-size:10pt;' value="<?= $this->nettoyer($ententeprealable['tm']) ?>" readonly> </td>
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</tr>
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</tbody>
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</table>
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<div id ="div_wait">
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</div>
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<!--
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<button type="button" style="font-size:10pt;" class="form-control btn btn-primary" onclick="javascript:afficher_dernieres_factures_optique('<?= $idBeneficiaire ?>');" > <?= _("Afficher les dernières factures...") ?> </button>
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<div id ="div_dernieres_factures_optique">
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</div>
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-->
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