96 lines
3.6 KiB
PHP
96 lines
3.6 KiB
PHP
<?php
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$this->titre = "INTER-SANTE - Nouveau Dossier Remboursement classique";
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?>
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<legend> <?= _("Nouveau Dossier Remboursement Classiqqe / Hors Tiers Payant") ?> </legend>
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<table class="table table-responsive table-condensed" style='font-size:10pt;'>
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<tbody>
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<tr>
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<td width="10%" > <?= _("Demandeur") ?> </td>
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<td width="45%" ><INPUT class="form-control" TYPE="text" id="demandeur" NAME="demandeur" style='font-size:10pt;' required autofocus></td>
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<td width="10%" align="center"> <?= _("Lien Parenté") ?> </td>
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<td>
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<SELECT class="form-control" id="codeLienDemandeur" NAME="codeLienDemandeur" required style='font-size:10pt;'>
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<?php liste_options($liendemandeur,""); ?>
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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> <?= _("Prestataire Cons") ?> </td>
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<td><INPUT style='font-size:10pt;' class="form-control" TYPE="text" id="prestataireConsultation" NAME="prestataireConsultation" ></td>
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<td align="center"> <?= _("Date Cons") ?> </td>
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<td> <INPUT class="form-control datepicker" TYPE="text" id="dateConsultation" NAME="dateConsultation" value="" required style='font-size:10pt;' ></td>
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</tr>
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<tr>
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<td> <?= _("Raison Consult") ?> </td>
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<td>
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<SELECT class="form-control" id="codeRaisonConsultation" NAME="codeRaisonConsultation" required autofocus style='font-size:10pt;'>
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<?php liste_options($raison, ""); ?>
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</SELECT>
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</td>
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<td align="center" > Hospit ?</td>
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<td>
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<SELECT class="form-control" id="hospitalisation" NAME="hospitalisation" style='font-size:10pt;' >
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<?php liste_options($ouinonhospit, ""); ?>
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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> <?= _("Bénéficiaire") ?> </td>
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<td ><INPUT class="form-control" TYPE="text" id="beneficiaireReglement" NAME="beneficiaireReglement" style='font-size:10pt;' required></td>
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<td align="center"> <?= _("Lien Parenté") ?> </td>
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<td>
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<SELECT class="form-control" id="codeLienBeneficiaire" NAME="codeLienBeneficiaire" required style='font-size:10pt;'>
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<?php liste_options($lienbeneficiaire,""); ?>
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</SELECT>
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</td>
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</tr>
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<tr>
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<td colspan="4"> <input style='text-align:center; font-size:11pt; background-color:green;color:white;' class="form-control" type="text" value= "Informations sur le paiement proposées par le bénéficiaire" disabled > </td>
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</tr>
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<tr>
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<td > <?= _("Mode P") ?> </td>
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<td>
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<SELECT class="form-control" id="codeModePaiementDemande" NAME="codeModePaiementDemande" required style='font-size:10pt;' >
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<?php liste_options($modepaiement,""); ?>
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</SELECT>
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</td>
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<td align="center"> <?= _("Banque Bénéf") ?> </td>
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<td>
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<SELECT style='font-size:10pt;' class="form-control" id="codeBanqueBeneficiaire" NAME="codeBanqueBeneficiaire" required>
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<?php liste_options($banque, ""); ?>
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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 Cpte Bénéf") ?> </td>
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<td > <INPUT style='font-size:10pt;' class="form-control" TYPE="text" id="numeroCompteBeneficiaire" NAME="numeroCompteBeneficiaire" required> </td>
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<td align="center"> Observations </td>
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<td ><INPUT class="form-control" TYPE="text" id="observations" NAME="observations" style='font-size:10pt;' ></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 id="btn_enreg" name="btn_enreg" class = "form-control btn btn-primary" type="button" value="<?= _("Enregistrer le Dossier...") ?>" onClick="javascript:enregistrer_dossier_classique();" style='font-size:10pt;' > </td>
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</tr>
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</tbody>
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</table>
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