178 lines
7.8 KiB
PHP
Executable File
178 lines
7.8 KiB
PHP
Executable File
<?php $this->titre = "INTER SANTE - Modification Bénéficiaire";
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//var_dump($beneficiaire['codeTarifActe']);
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?>
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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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<!--<INPUT class="form-control" TYPE="text" id="chemin" NAME="chemin" value="<?= $chemin ?>" readonly>-->
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<INPUT class="sr-only" TYPE="text" id="genreAdherent" NAME="genreAdherent" value="<?= $this->nettoyer($adherent['sexe']) ?>">
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<INPUT class="sr-only" TYPE="text" id="idCollege" NAME="idCollege" value="<?= $this->nettoyer($adherent['idCollege']) ?>">
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<div id="div_age_max">
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</div>
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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="13%" > <?= _("Nom Adhérent") ?> </td>
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<td width="37%" ><INPUT class="form-control majuscule" TYPE="text" id="nomadherent" name="nomadherent" value="<?= $adherent['nom'] ?>" readonly ></td>
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<td width="15%" align="center"> <?= _("Prénoms") ?> </td>
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<td width="37%"><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="<?= $adherent['libelleCollege'] ?>" readonly ></td>
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<td align="center" class="required"> <?= _("Entrée") ?> </td>
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<td><INPUT class="form-control datepicker" TYPE="text" id="dateEntree" NAME="dateEntree" value="<?= dateLang($this->nettoyer($beneficiaire['dateEntree'])) ?>" required AUTOCOMPLETE="OFF"></td>
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</tr>
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<tr>
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<td class="required"> <?= _("Nom Bénéficiaire") ?> </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" class="required"> <?= _("Prénoms") ?> </td>
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<td><INPUT class="form-control majuscule" TYPE="text" id="prenomsBeneficiaire" NAME="prenomsBeneficiaire" value="<?= $beneficiaire['prenomsBeneficiaire'] ?>" required AUTOCOMPLETE="OFF" autofocus></td>
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</tr>
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<tr>
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<td class="required"> <?= _("Lien Parenté") ?> </td>
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<td>
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<SELECT class="form-control" id="codeLienParente" NAME="codeLienParente" required AUTOCOMPLETE="OFF" onchange="javascript:filtrergenreconjoint(); agemaxbeneficiaire();">
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<?php liste_options($lienparente,$beneficiaire['codeLienParente'],true); ?>
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</SELECT>
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</td>
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<td align="center" class="required"> <?= _("Naissance") ?> </td>
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<td><INPUT class="form-control datepicker" TYPE="text" id="dateNaissance" NAME="dateNaissance" value="<?= dateLang($this->nettoyer($beneficiaire['dateNaissance'])) ?>" required AUTOCOMPLETE="OFF"></td>
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</tr>
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<tr>
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<td class="required">Genre</td>
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<td>
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<SELECT class="form-control" id="sexe" NAME="sexe" required AUTOCOMPLETE="OFF">
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<?php liste_options($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,$beneficiaire['codeGroupeSanguin'],true); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td><?= _("Nature Pièce") ?></td>
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<td>
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<SELECT class="form-control" id="codeNaturePiece" NAME="codeNaturePiece">
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<?php liste_options($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 Portable") ?> </td>
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<td><INPUT class="form-control" TYPE="tel" id="telephonePortable" NAME="telephonePortable" value="<?= $beneficiaire['telephonePortable'] ?>"></td>
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<td align="center"><?= _("Tarif Actes") ?></td>
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<td >
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<select name="codeTarifActe" id="codeTarifActe" class="form-control selectpicker" data-live-search="true">
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<?= liste_options($tarifActe,$beneficiaire['codeTarifActe'], false) ?>
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</select>
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</td>
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</tr>
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<tr>
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<td ><?= _("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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<td align="center"><?= _("Matricule Employé") ?></td>
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<td >
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<INPUT class="form-control" id="numeroMatricule" name="numeroMatricule" TYPE="text" value="<?= $beneficiaire['numeroMatricule']; ?>">
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</td>
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</tr>
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<tr>
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<td ><?= _("Date Souscription") ?></td>
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<td >
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<INPUT class="form-control datepicker" id="dateSouscription" name="dateSouscription" TYPE="text" value="<?= datefr($beneficiaire['dateSouscription']); ?>">
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</td>
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<td align="center"><?= _("VIP") ?></td>
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<td >
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<SELECT class="form-control" id="vip" NAME="vip">
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<?php liste_options($ouinonvip,$beneficiaire['vip'],true); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td > <?= _("Seuil RD (%)") ?> </td>
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<td>
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<INPUT class="form-control" TYPE="number" id="seuilRdBeneficiaire" NAME="seuilRdBeneficiaire" value="<?= $beneficiaire['seuilRdBeneficiaire']; ?>" min="0" max="100">
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</td>
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<td align="center"><?= _("No Bulletin Santé") ?></td>
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<td><INPUT style='font-size:10pt;' class="form-control" id="numeroBs" NAME="numeroBs" TYPE="text" value="<?= $beneficiaire['numeroBs']; ?>"></td>
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</tr>
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<tr>
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<td> <?= _("Ancien No Assuré") ?> </td>
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<td> <INPUT style='font-size:10pt;' class="form-control" id="ancienNumeroAssure" NAME="ancienNumeroAssure" TYPE="text" value="<?= $beneficiaire['ancienNumeroAssure']; ?>" readonly></td>
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<td align="center"> <?= _("Conserver Ancien No ?") ?> </td>
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<td align="center">
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<SELECT class="form-control" id="conserverAncienNumeroAssure" NAME="conserverAncienNumeroAssure" readonly>
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<?php liste_options($ouinonconserver,$beneficiaire['conserverAncienNumeroAssure'],true); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td > <?= _("Type Remboursement") ?> </td>
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<td >
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<SELECT style="font-size:10pt;" class="form-control" id="codeTypeRemboursement" NAME="codeTypeRemboursement">
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<?php liste_options($typeremboursement,$this->nettoyer($beneficiaire['codeTypeRemboursement']),true); ?>
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</SELECT>
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</td>
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<td > </td>
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<td align="center">
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<INPUT style='font-size:10pt;' class="form-control" TYPE="text" value="" disabled>
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</td>
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</tr>
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<tr>
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<td colspan="4" style="height:8px; background-color:white;">
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</td>
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</tr>
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<tr>
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<td colspan="4" ><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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