radiantrh/Vue/Modifierbeneficiaire/index.php

<?php $this->titre = "INTER-SANTE - Modification Bénéficiaire"; ?>

<div class="container-fluid py-4">
    <form method="post" action="Modifierbeneficiaire/modifier/<?=$beneficiaire['id']?>/">
        
        <input type="hidden" id="idPolice" name="idPolice" value="<?= $_SESSION['idPolice_C'] ?>">
        <input type="hidden" id="numeroPolice" name="numeroPolice" value="<?= $_SESSION['numeroPolice_C'] ?>">
        <input type="hidden" id="idAdherent" name="idAdherent" value="<?= $_SESSION['idAdherent_C'] ?>">
        <input type="hidden" id="numeroAdherent" name="numeroAdherent" value="<?= $_SESSION['numeroAdherent_C'] ?>">
        <input type="hidden" id="codeProduit" name="codeProduit" value="<?= $adherent['codeProduit'] ?>">

        <div class="card shadow-sm border-0">
            <div class="card-header bg-primary text-white py-3">
                <h5 class="mb-0">
                    <i class="fas fa-user-edit me-2"></i>
                    <?= _("Informations sur le Bénéficiaire") ?> : <span class="badge bg-white text-primary ms-2"><?= $beneficiaire['numeroBeneficiaire'] ?></span>
                </h5>
            </div>

            <div class="card-body p-4">
                <h6 class="text-muted text-uppercase small fw-bold mb-3 border-bottom pb-2"><?= _("Référence Adhérent") ?></h6>
                <div class="row g-3 mb-4 bg-light p-3 rounded">
                    <div class="col-md-6">
                        <label class="form-label small text-muted mb-0"><?= _("Nom & Prénoms Adhérent") ?></label>
                        <div class="fw-bold"><?= $adherent['nom'] ?> <?= $adherent['prenoms'] ?></div>
                    </div>
                    <div class="col-md-6 border-start">
                        <label class="form-label small text-muted mb-0"><?= _("Collège / Produit") ?></label>
                        <div class="fw-bold"><?= $adherent['libelleCollege'] ?></div>
                    </div>
                </div>

                <h6 class="text-muted text-uppercase small fw-bold mb-3 border-bottom pb-2"><?= _("Données du Bénéficiaire") ?></h6>
                <div class="row g-3">
                    <div class="col-md-6">
                        <label class="form-label fw-bold small"><?= _("Date d'Entrée") ?> <span class="text-danger">*</span></label>
                        <input class="form-control datepicker" type="text" id="dateEntree" name="dateEntree" value="<?= dateLang($this->nettoyer($beneficiaire['dateEntree'])) ?>" required>
                    </div>
                    <div class="col-md-6">
                        <label class="form-label fw-bold small"><?= _("Date de Naissance") ?> <span class="text-danger">*</span></label>
                        <input class="form-control datepicker" type="text" id="dateNaissance" name="dateNaissance" value="<?= dateLang($this->nettoyer($beneficiaire['dateNaissance'])) ?>" required>
                    </div>

                    <div class="col-md-6">
                        <label class="form-label fw-bold small"><?= _("Nom") ?> <span class="text-danger">*</span></label>
                        <input class="form-control text-uppercase" type="text" id="nomBeneficiaire" name="nomBeneficiaire" value="<?= $beneficiaire['nomBeneficiaire'] ?>" required>
                    </div>
                    <div class="col-md-6">
                        <label class="form-label fw-bold small"><?= _("Prénoms") ?> <span class="text-danger">*</span></label>
                        <input class="form-control" type="text" id="prenomsBeneficiaire" name="prenomsBeneficiaire" value="<?= $beneficiaire['prenomsBeneficiaire'] ?>" required autofocus>
                    </div>

                    <div class="col-md-4">
                        <label class="form-label fw-bold small"><?= _("Lien Parenté") ?></label>
                        <select class="form-select" id="codeLienParente" name="codeLienParente">
                            <?php liste_options($lienparente,$beneficiaire['codeLienParente'],true); ?>
                        </select>
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small"><?= _("Sexe") ?></label>
                        <select class="form-select" id="sexe" name="sexe">
                            <?php liste_options($sexe,$beneficiaire['sexe'],true); ?>
                        </select>
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small"><?= _("Groupe Sanguin") ?></label>
                        <select class="form-select" id="codeGroupeSanguin" name="codeGroupeSanguin">
                            <?php liste_options($groupesanguin,$beneficiaire['codeGroupeSanguin'],true); ?>
                        </select>
                    </div>

                    <div class="col-md-4">
                        <label class="form-label fw-bold small"><?= _("Nature Pièce") ?></label>
                        <select class="form-select" id="codeNaturePiece" name="codeNaturePiece">
                            <?php liste_options($naturepiece,$beneficiaire['codeNaturePiece'],true); ?>
                        </select>
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small"><?= _("N° Pièce") ?></label>
                        <input class="form-control" type="text" id="numeroPiece" name="numeroPiece" value="<?=$beneficiaire['numeroPiece']?>">
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small"><?= _("Téléphone Portable") ?></label>
                        <div class="input-group">
                            <span class="input-group-text"><i class="fas fa-phone"></i></span>
                            <input class="form-control" type="tel" id="telephonePortable" name="telephonePortable" value="<?= $beneficiaire['telephonePortable'] ?>">
                        </div>
                    </div>
                </div>

                <div class="row mt-5">
                    <div class="col-12 text-end">
                        <hr>
                        <a href="javascript:history.back()" class="btn btn-outline-secondary me-2">
                            <i class="fas fa-times me-2"></i><?= _("Annuler") ?>
                        </a>
                        <button type="submit" class="btn btn-primary px-5 shadow-sm">
                            <i class="fas fa-save me-2"></i><?= _("Enregistrer les modifications") ?>
                        </button>
                    </div>
                </div>
            </div>
        </div>
    </form>
</div>