49 lines
2.5 KiB
PHP
Executable File
49 lines
2.5 KiB
PHP
Executable File
<?php
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$this->titre = "Intersanté - Rechercher sinistre";
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?>
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<form id="frmrechercheprestation" name="frmrechercheprestation" method="post" action="Rechercheprestations/index/" style='font-size:10pt;' >
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<legend> Critères de recherche dossiers sinistres </legend>
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<table class="table table-condensed table-responsive" style='font-size:10pt;'>
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<tbody>
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<tr>
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<td width="15%" > <?= _("Bon Cons") ?> </td>
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<!-- <td><INPUT autofocus style='font-size:10pt;text-align:center;' class="form-control" type="number" id="numeroBonConsultation" name="numeroBonConsultation" placeholder="Consultation"></td> -->
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<td><INPUT autofocus style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonConsultation" name="numeroBonConsultation" placeholder="Consultation"></td>
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<td align="center" width="15%"> Bon Pharmacie </td>
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<td><INPUT style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonOrdonnance" NAME="numeroBonOrdonnance" placeholder="Pharmacie"></td>
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</tr>
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<tr>
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<td> Bon Hospitalisation </td>
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<td><INPUT style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonHospitalisation" NAME="numeroBonHospitalisation" placeholder="Hospitalisation"></td>
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<td align="center"> Prescription Exam </td>
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<td><INPUT style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonExamen" NAME="numeroBonExamen" placeholder="Examen"></td>
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</tr>
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<tr>
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<td> Bon Optique </td>
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<td><INPUT style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonOptique" NAME="numeroBonOptique" placeholder="Optique"></td>
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<td align="center"> Prescription Kine</td>
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<td><INPUT style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonKine" NAME="numeroBonKine" placeholder="Prescript°"></td>
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</tr>
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<tr>
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<td> Séances Kine </td>
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<td><INPUT style='font-size:10pt;text-align:center;' class="form-control" type="text" id="numeroBonSeance" NAME="numeroBonSeance" placeholder="Séances"></td>
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<td> </td>
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<td><input style='font-size:10pt;text-align:center;' id="lancerrecherche" name="lancerrecherche" class="form-control btn btn-primary" type="submit" value="Lancer la Recherche ..."/></td>
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</tr>
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</tbody>
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</table>
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</form>
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<div class="alert alert-danger">
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<H3> <?= $message_recherche ?> </H3>
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</div>
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