291 lines
12 KiB
PHP
Executable File
291 lines
12 KiB
PHP
Executable File
<?php $this->titre = "INTER SANTE - Modification Adhérent";
|
|
$superUser = $_SESSION['superUser'];
|
|
?>
|
|
|
|
<form method="post" action="Modifieradherent/modifier/<?=$this->nettoyer($adherent['id'])?>/">
|
|
<INPUT class="sr-only" TYPE="text" id="nomForm" name="nomForm" value="frmmodifieradherent">
|
|
<INPUT class="sr-only" TYPE="text" id="idPolice" name="idPolice" value="<?= $_SESSION['idPolice_C'] ?>">
|
|
<INPUT class="sr-only" TYPE="text" id="numeroPolice" name="numeroPolice" value="<?= $_SESSION['numeroPolice_C'] ?>">
|
|
<INPUT class="sr-only" TYPE="text" id="codeEtatFacturation" name="codeEtatFacturation" value="<?=$this->nettoyer($adherent['codeEtatFacturation']);?>" >
|
|
<INPUT class="sr-only" TYPE="text" id="consommation_adherent" name="consommation_adherent" value="<?=$this->nettoyer($adherent['consommation_adherent']);?>" >
|
|
<INPUT class="sr-only" TYPE="text" id="rapport_sp_police" name="rapport_sp_police" value="<?=$this->nettoyer($adherent['rapport_sp_police']);?>" >
|
|
<INPUT class="sr-only" TYPE="text" id="idCollege" name="idCollege" value="<?=$this->nettoyer($adherent['idCollege']);?>" >
|
|
|
|
|
|
<INPUT class="sr-only" TYPE="text" id="idAdherent" name="idAdherent" value="<?= $this->nettoyer($adherent['id']); ?>">
|
|
<INPUT class="sr-only" TYPE="text" id="codeLienParente" name="codeLienParente" value="A">
|
|
|
|
<div id="div_age_max">
|
|
</div>
|
|
|
|
<fieldset>
|
|
<legend><?= _("Informations sur le chef de Famille / Adhérent Numéro") . " : " . $this->nettoyer($adherent['numeroAdherent']);?></legend>
|
|
|
|
<table class="table table-responsive table-condensed">
|
|
<tbody>
|
|
<tr>
|
|
<td width="13%"> <?= _("Client") ?> </td>
|
|
<td width="37%" ><INPUT class="form-control" TYPE="text" id="nomClient" name="nomClient" value="<?= $_SESSION['nomClient_C'] ?>" readonly ></td>
|
|
|
|
<td width="16%" align="center"> <?= _("Collège") ?> </td>
|
|
<td ><INPUT class="form-control" TYPE="text" value="<?=$this->nettoyer($adherent['libelleCollege']);?>" readonly ></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="required"> <?= _("Nom Adhérent") ?> </td>
|
|
<td><INPUT class="form-control majuscule" TYPE="text" id="nom" NAME="nom" value="<?=$this->nettoyer($adherent['nom']);?>" required AUTOCOMPLETE="OFF" ></td>
|
|
|
|
<td align="center" class="required"> <?= _("Prénoms") ?> </td>
|
|
<td><INPUT class="form-control majuscule" TYPE="text" id="prenoms" NAME="prenoms" value="<?=$this->nettoyer($adherent['prenoms']);?>" required AUTOCOMPLETE="OFF"></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td ><?= _("Nature Pièce") ?></td>
|
|
<td>
|
|
<select class="form-select" id="codeNaturePiece" NAME="codeNaturePiece">
|
|
<?php liste_options($naturepiece,$this->nettoyer($adherent['codeNaturePiece']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
|
|
<td align="center"><?= _("No Pièce") ?></td>
|
|
<td>
|
|
<INPUT class="form-control majuscule" TYPE="text" id="numeroPiece" NAME="numeroPiece" value="<?=$this->nettoyer($adherent['numeroPiece']);?>" >
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td><?= _("No CMU") ?></td>
|
|
<td>
|
|
<INPUT class="form-control majuscule" TYPE="text" id="numeroCmu" NAME="numeroCmu" value="<?=$this->nettoyer($adherent['numeroCmu']);?>" >
|
|
</td>
|
|
|
|
<td align="center"><?= _("Matricule Employé") ?></td>
|
|
<td>
|
|
<INPUT class="form-control majuscule" TYPE="text" id="numeroMatricule" NAME="numeroMatricule" value="<?=$this->nettoyer($adherent['numeroMatricule']);?>">
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td class="required"><?= _("Genre") ?></td>
|
|
<td>
|
|
<select class="form-select" id="sexe" NAME="sexe" required AUTOCOMPLETE="OFF">
|
|
<?php liste_options($sexe,$this->nettoyer($adherent['sexe']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
|
|
<td align="center"> <?= _("Date Naissance") ?> </td>
|
|
<td><INPUT class="form-control datepicker" TYPE="text" id="dateNaissance" NAME="dateNaissance" value="<?= dateLang($this->nettoyer($adherent['dateNaissance'])) ?>"></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Groupe Sanguin") ?> </td>
|
|
<td>
|
|
<select class="form-select" id="codeGroupeSanguin" NAME="codeGroupeSanguin">
|
|
<?php liste_options($groupesanguin,$this->nettoyer($adherent['codeGroupeSanguin']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
|
|
<td align="center"> <?= _("Situation Familiale") ?> </td>
|
|
<td>
|
|
<select class="form-select" id="codeSituationFamille" NAME="codeSituationFamille">
|
|
<?php liste_options($situationfamille,$this->nettoyer($adherent['codeSituationFamille']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
|
|
<td> <?= _("Nombre Enfants") ?> </td>
|
|
<td><input class="form-control" type="number" id="nombreEnfants" name="nombreEnfants" min="0" max="10" value="<?= $adherent['nombreEnfants'] ?>"></td>
|
|
|
|
<td align="center"> <?= _("Pays") ?> </td>
|
|
<td>
|
|
<SELECT onChange="ajaxListerVille();" class="form-select" id="codePays" NAME="codePays">
|
|
<?php liste_options($pays,$this->nettoyer($adherent['codePays']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= (isset($_SESSION['affichagedynamique']['Région / District'])) ? _($_SESSION['affichagedynamique']['Région / District']) : _("Région / District") ?> </td>
|
|
<td>
|
|
<div id="listeville">
|
|
<SELECT onChange="ajaxListerLocalite();" class="form-select" id="codeVille" NAME="codeVille">
|
|
<?php liste_options($ville, $this->nettoyer($adherent['codeVille']), true ); ?>
|
|
</SELECT>
|
|
</div>
|
|
</td>
|
|
|
|
<td align="center"> <?= (isset($_SESSION['affichagedynamique']['Commune'])) ? _($_SESSION['affichagedynamique']['Commune']) : _("Commune") ?> </td>
|
|
<td>
|
|
<div id="listelocalite">
|
|
<select class="form-select" id="codeLocalite" NAME="codeLocalite">
|
|
<?php liste_options($localite, $this->nettoyer($adherent['codeLocalite']),true); ?>
|
|
</SELECT>
|
|
</div>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Indicatif") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="text" id="prefixePaiementMobile" NAME="prefixePaiementMobile" value="<?= $this->nettoyer($adherent['prefixePaiementMobile']); ?>"></td>
|
|
|
|
<td align="center"> <?= _("Mobile Paiement") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="text" id="mobilePaiement" NAME="mobilePaiement" title="<?= _("L'indicatif est obligatoire")?>" value="<?= $this->nettoyer($adherent['mobilePaiement']); ?>"></td>
|
|
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Tél Portable") ?> </td>
|
|
<td>
|
|
<INPUT class="form-control" TYPE="tel" id="telephonePortable" NAME="telephonePortable" value="<?= $this->nettoyer($adherent['telephonePortable']); ?>" >
|
|
</td>
|
|
|
|
<td align="center"> <?= _("Tél Fixe") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="tel" id="telephonFixe" NAME="telephonFixe" value="<?= $this->nettoyer($adherent['telephonFixe']); ?>"></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Entrée") ?> </td>
|
|
<td><INPUT class="form-control datepicker" TYPE="text" id="dateEntree" NAME="dateEntree" value="<?= dateLang($this->nettoyer($adherent['dateEntree'])); ?>" disabled></td>
|
|
|
|
<td align="center">E-mail</td>
|
|
<td>
|
|
<INPUT class="form-control" TYPE="email" id="email" NAME="email" value="<?= $this->nettoyer($adherent['email']); ?>">
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td ><?= _("Date Souscription") ?></td>
|
|
<td ><INPUT class="form-control datepicker" TYPE="text" id="dateSouscription" name="dateSouscription" value="<?= datefr($this->nettoyer($adherent['dateSouscription']))?>"></td>
|
|
<td align="center"><?= _("VIP") ?></td>
|
|
<td >
|
|
<select class="form-select" id="vip" NAME="vip">
|
|
<?php liste_options($ouinonvip,$this->nettoyer($adherent['vip']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("S / P Police") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="text" value="<?= $this->nettoyer($adherent['rapport_sp_police']) ?>" readonly></td>
|
|
|
|
<td align="center"><?= _("Tarif Actes") ?></td>
|
|
<td >
|
|
<select name="codeTarifActe" id="codeTarifActe" class="form-control selectpicker" data-live-search="true">
|
|
<?= liste_options($tarifActe,$this->nettoyer($adherent['codeTarifActe']), false) ?>
|
|
</select>
|
|
</td>
|
|
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Ancien No Assuré") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="text" id="ancienNumeroAssure" NAME="ancienNumeroAssure" value="<?= $this->nettoyer($adherent['ancienNumeroAssure']); ?>"></td>
|
|
|
|
<td align="center"> <?= _("No Bulletin Santé") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="text" id="numeroBs" NAME="numeroBs" value="<?= $adherent['numeroBs'] ?>"></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Seuil RD (%)") ?> </td>
|
|
<td><INPUT class="form-control" TYPE="text" value="<?= $this->nettoyer($adherent['seuilRdAdherent']) ?>" id="seuilRdAdherent" NAME="seuilRdAdherent" TYPE="number" value="0" min="0" max="100"></td>
|
|
|
|
<td align="center"> <?= _("Type Remboursement") ?> </td>
|
|
<td >
|
|
<SELECT style="font-size:10pt;" class="form-select" id="codeTypeRemboursement" NAME="codeTypeRemboursement">
|
|
<?php liste_options($typeremboursement,$this->nettoyer($adherent['codeTypeRemboursement']),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td> <?= _("Adresse Géographique") ?> </td>
|
|
<td ><INPUT class="form-control" TYPE="text" id="adresseGeo" NAME="adresseGeo" value="<?= $this->nettoyer($adherent['adresseGeo']) ?>"></td>
|
|
|
|
<td align="center"> <?= _("Adresse Postale") ?> </td>
|
|
<td ><INPUT class="form-control" TYPE="text" id="adressePostale" NAME="adressePostale" value="<?= $this->nettoyer($adherent['adressePostale']) ?>"></td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="4">
|
|
<legend ><?= _("BENEFICIAIRE DE REMBOURSEMENT DIRECT"); ?> </legend >
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="4">
|
|
<button style="font-size:12pt;" class="form-control btn btn-secondary" TYPE="button" onclick="javascript:affiche_beneficiaire_remboursement();">
|
|
<?= _("Changer le Bénéficiaire de Remboursement Direct") ?>
|
|
</button>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td > <?= _("Bénéficiaire") ?> </td>
|
|
<td ><INPUT class="form-control majuscule" TYPE="text" style='font-size:10pt;' disabled
|
|
value="<?= $this->nettoyer($beneficiaireRD["beneficiaireReglement"]); ?>">
|
|
</td>
|
|
|
|
<td align="center"> <?= _("Lien Parenté") ?> </td>
|
|
<td>
|
|
<select class="form-select" disabled style='font-size:10pt;' >
|
|
<?php liste_options($lienbeneficiaire,$this->nettoyer($beneficiaireRD["codeLienBeneficiaire"]),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td > <?= _("Mode Paiement") ?> </td>
|
|
<td>
|
|
<select class="form-select" disabled style='font-size:10pt;' >
|
|
<?php liste_options($modepaiement,$this->nettoyer($beneficiaireRD["codeModePaiement"]),true); ?>
|
|
</SELECT>
|
|
</td>
|
|
|
|
<td align="center"> <?= _("En vigueur") ?> </td>
|
|
<td>
|
|
<SELECT style='font-size:10pt;' class="form-select" disabled>
|
|
<?php liste_options($ouinonenvigueur, "1",true); ?>
|
|
</SELECT>
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td > <?= _("Téléphone Portable") ?> </td>
|
|
<td>
|
|
<INPUT class="form-control" TYPE="text" style='font-size:10pt;' disabled
|
|
value="<?= $this->nettoyer($beneficiaireRD["telephoneMobile"]); ?>">
|
|
</td>
|
|
|
|
<td align="center"> <?= _("RIB") ?> </td>
|
|
<td>
|
|
<INPUT class="form-control majuscule" TYPE="text" style='font-size:10pt;' readonly
|
|
value="<?= $this->nettoyer($beneficiaireRD["rib"]); ?>">
|
|
</td>
|
|
</tr>
|
|
|
|
<tr>
|
|
<td colspan="4"><input class = "form-control btn btn-primary" type="submit" value="<?= _("Enregistrer") ?>" /></td>
|
|
|
|
</tr>
|
|
</tbody>
|
|
</table>
|
|
</fieldset>
|
|
|
|
<div id="infottc" style="display: none">
|
|
<input type="text" id="primeTtc_info" name="primeTtc_info" >
|
|
</div>
|
|
|
|
<div id="div_beneficiaire_remboursement" class="modal fade" data-bs-backdrop="static" data-bs-keyboard="false">
|
|
|
|
</div>
|
|
|
|
</form>
|
|
|
|
<?php if (isset($msgErreur)): ?>
|
|
<div class="alert alert-danger" style="height:30px; padding:5px;" >
|
|
<H4><?= $msgErreur ?></H4>
|
|
</div>
|
|
<?php endif; ?>
|