95 lines
4.5 KiB
PHP
95 lines
4.5 KiB
PHP
<?php $this->titre = "INTER-SANTE - Modification Bénéficiaire"; ?>
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<form method="post" action="Modifierbeneficiaire/modifier/<?=$beneficiaire['id']?>/">
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<INPUT class="sr-only" TYPE="text" id="idPolice" name="idPolice" value="<?= $_SESSION['idPolice_C'] ?>">
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<INPUT class="sr-only" TYPE="text" id="numeroPolice" name="numeroPolice" value="<?= $_SESSION['numeroPolice_C'] ?>">
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<INPUT class="sr-only" TYPE="text" id="idAdherent" name="idAdherent" value="<?= $_SESSION['idAdherent_C'] ?>">
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<INPUT class="sr-only" TYPE="text" id="numeroAdherent" name="numeroAdherent" value="<?= $_SESSION['numeroAdherent_C'] ?>">
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<INPUT class="sr-only" TYPE="text" id="codeProduit" name="codeProduit" value="<?= $adherent['codeProduit'] ?>">
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<fieldset>
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<legend> <?= _("Informations sur le Bénéficiaire") . " : " . $beneficiaire['numeroBeneficiaire']?> </legend>
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<table class="table table-responsive table-condensed">
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<tbody>
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<tr>
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<td width="10%" > <?= _("Nom Adhérent") ?> </td>
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<td width="40%" ><INPUT class="form-control majuscule" TYPE="text" id="nomadherent" name="nomadherent" value="<?= $adherent['nom'] ?>" readonly ></td>
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<td width="10%" align="center"> <?= _("Prénoms") ?> </td>
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<td><INPUT class="form-control majuscule" TYPE="text" id="prenomadherent" name="prenomadherent" value="<?= $adherent['prenoms'] ?>" readonly ></td>
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</tr>
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<tr>
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<td> <?= _("Collège") ?> </td>
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<td><INPUT class="form-control" TYPE="text" id="produit" name="produit" value="<?= $adherent['libelleCollege'] ?>" readonly ></td>
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<td align="center"> <?= _("Entrée") ?> </td>
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<td><INPUT class="form-control datepicker" TYPE="text" id="dateEntree" NAME="dateEntree" value="<?= dateLang($this->nettoyer($beneficiaire['dateEntree'])) ?>" required AUTOCOMPLETE="OFF" ></td>
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</tr>
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<tr>
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<td> <?= _("Nom Bénéf") ?> </td>
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<td><INPUT class="form-control majuscule" TYPE="text" id="nomBeneficiaire" NAME="nomBeneficiaire" value="<?= $beneficiaire['nomBeneficiaire'] ?>" required AUTOCOMPLETE="OFF" ></td>
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<td align="center"> <?= _("Prénoms") ?> </td>
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<td><INPUT class="form-control majuscule" TYPE="text" id="prenomsBeneficiaire" NAME="prenomsBeneficiaire" value="<?= $beneficiaire['prenomsBeneficiaire'] ?>" required AUTOCOMPLETE="OFF" autofocus></td>
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</tr>
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<tr>
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<td> <?= _("Lien Parenté") ?> </td>
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<td>
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<SELECT class="form-control" id="codeLienParente" NAME="codeLienParente">
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<?php liste_options($lienparente,$beneficiaire['codeLienParente'],true); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("Naissance") ?> </td>
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<td><INPUT class="form-control datepicker" TYPE="text" id="dateNaissance" NAME="dateNaissance" value="<?= dateLang($this->nettoyer($beneficiaire['dateNaissance'])) ?>" required AUTOCOMPLETE="OFF" ></td>
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</tr>
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<tr>
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<td>Genre</td>
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<td>
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<SELECT class="form-control" id="sexe" NAME="sexe">
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<?php liste_options($sexe,$beneficiaire['sexe'],true); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("Groupe Sanguin") ?> </td>
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<td>
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<SELECT class="form-control" id="codeGroupeSanguin" NAME="codeGroupeSanguin">
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<?php liste_options($groupesanguin,$beneficiaire['codeGroupeSanguin'],true); ?>
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</SELECT>
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</td>
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</tr>
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<td><?= _("Nature Pièce") ?></td>
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<td>
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<SELECT class="form-control" id="codeNaturePiece" NAME="codeNaturePiece">
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<?php liste_options($naturepiece,$beneficiaire['codeNaturePiece'],true); ?>
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</SELECT>
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</td>
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<td align="center"><?= _("No Pièce") ?></td>
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<td><INPUT class="form-control majuscule" TYPE="text" id="numeroPiece" NAME="numeroPiece" value="<?=$beneficiaire['numeroPiece']?>"></td>
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</tr>
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<tr>
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<td> <?= _("Tél Port") ?> </td>
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<td><INPUT class="form-control" TYPE="tel" id="telephonePortable" NAME="telephonePortable" value="<?= $beneficiaire['telephonePortable'] ?>"></td>
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<td align="center"><?= _("No CMU") ?> </td>
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<td><INPUT class="form-control majuscule" TYPE="tel" id="numeroCmu" NAME="numeroCmu" value="<?= $beneficiaire['numeroCmu'] ?>"></td>
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</tr>
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<tr>
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<td></td>
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<td colspan="3"><input class = "form-control btn btn-primary" type="submit" value="<?= _("Enregistrer") ?>" /></td>
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</tr>
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</tbody>
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</table>
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</fieldset>
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</form>
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