File: /home/imensosw/www/imenso.co/dev/lavender-old/booking-details.php
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<html lang="en-US" >
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<link rel="profile" href="http://gmpg.org/xfn/11">
<title>Lavender Medical</title>
<link rel='stylesheet' href='css/bootstrap.min.css' media='all' />
<link rel='stylesheet' href='css/style.css' media='all' />
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</head>
<body>
<?php include('header.php'); ?>
<section class="b-burger">
<div class="container">
<h1 class="date-scroll pt-4"> <a href="bookings.php"><i class="fa fa-long-arrow-left smbtn"></i> <strong>Back</strong></a></h1>
<form>
<div class="row pt-4">
<div class="col-lg-8">
<div class="d-card">
<h4>Basic Details</h4>
<div class="form-group">
<label>Hospital Name</label>
<select class="chosen-select">
<option>Bupa Cromwell</option>
<option>Hillsborough Clinic</option>
<option>Freeman Hospital</option>
<option>Bupa Cromwell</option>
</select>
</div>
<div class="form-group">
<div class="info">
<div class="info-left">
<strong>John Wick </strong> <a href="javascript:;" data-toggle="modal" data-target="#infoHospital" class="ml-3"><small><i class="fa fa-pencil mr-2" title="Edit Info"></i>Edit</small></a><br>
<small>Location: 45 East Block NY</small><br>
<small>Email: johnwich@bupa.com</small><br>
<small>Phone: 9988776655</small>
</div>
</div>
</div>
<div class="form-group">
<label>Operation Name</label>
<select class="chosen-select">
<option>Select</option>
<option>Appendectomy</option>
<option>C-Section</option>
<option>Heart Bypass Surgery</option>
<option><a href="#" class="btn sml-btn">Add New</a></option>
</select>
</div>
</div>
<div class="d-card mt-4">
<h4>Purchase/Hire Details</h4>
<div class="form-group">
<label>PO Number</label>
<input type="" class="form-control" name="">
</div>
<div class="form-group">
<label>Select Kit</label>
<select class="chosen-select">
<option>Select</option>
<option>RTS MTP implant - Set 01</option>
<option>RTS MTP implant - Set 02</option>
<option>RTS MTP implant - Set 03</option>
</select>
</div>
<div class="mt-4">
<table class="table">
<thead>
<tr>
<th>Image</th>
<th>Kit Name</th>
<th></th>
<th class="text-right">Qty</th>
<th></th>
</tr>
</thead>
<tbody>
<tr>
<td><img src="images/kit1.png" width="60"></td>
<td>RTS MTP implant - Set 01</td>
<td><a href="javascript:;" data-toggle="modal" data-target="#kitDetails" class="btn btn-bordered sml-text">View Details</a></td>
<td><input type="text" class="form-control sml-input" name="" value="2"></td>
<td><a href=""><i class="fa fa-trash"></i> </a></td>
</tr>
<tr>
<td><img src="images/kit1.png" width="60"></td>
<td>RTS MTP implant - Set 01</td>
<td><a href="javascript:;" data-toggle="modal" data-target="#kitDetails" class="btn btn-bordered sml-text">View Details</a></td>
<td><input type="text" class="form-control sml-input" name="" value="2"></td>
<td><a href=""><i class="fa fa-trash"></i> </a></td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
<div class="col-lg-4">
<div class="d-card">
<h4>Important Dates</h4>
<div class="form-group">
<label >Delivery date</label>
<input id="datepicker" value="3/9/2022 8:00 AM" />
</div>
<div class="form-group">
<label >Operation date</label>
<input id="datepicker2" value="3/12/2022 10:00 AM" />
</div>
<div class="form-group">
<label>Collection date</label>
<input id="datepicker3" value="3/13/2022 11:00 AM" />
</div>
<div class="alert alert-success" role="alert">Nice! The kit is available</div>
</div>
<div class="d-card mt-4">
<h4>Charges</h4>
<div class="form-group">
<label>Hire Charge</label>
<input id="" type="text" class="form-control" value="" />
</div>
<div class="form-group">
<label>Shipping Charge</label>
<input id="" type="text" class="form-control" value="" />
</div>
</div>
<div class="d-card mt-4">
<h4>Booked By</h4>
<div class="form-group">
<label>Rep Name</label>
<input id="" type="text" class="form-control" value="" />
</div>
<div class="form-group">
<label>Rep Email</label>
<input id="" type="text" class="form-control" value="" />
</div>
</div>
<div class="d-card mt-4">
<h4>Additional Notes</h4>
<div class="form-group">
<textarea class="form-control" rows="4"></textarea>
</div>
</div>
<div class="mt-5 text-right">
<a href="kits.php" class="btn btn-secondary mr-2">Cancel</a>
<a href="kits.php" class="btn btn-primary">Save Changes</a>
</div>
</form>
</div>
</div><!--/row-->
</div>
</section>
<!-- Hospital Info Modal -->
<div class="modal fade bigModal" id="infoHospital" tabindex="-1" role="dialog" aria-labelledby="" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="">Hospital Info</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<form class="row">
<div class="col-lg-6">
<div class="form-group">
<label>Switch Board Phone Number</label>
<input type="" class="form-control" name="" value="9988776655">
</div>
<div class="form-group">
<label>Contact Person Name</label>
<input type="" class="form-control" name="" value="John Wich">
</div>
<div class="form-group">
<label>Contact Person Phone Number</label>
<input type="" class="form-control" name="" value="9977885522">
</div>
<div class="form-group">
<label>Email Address</label>
<input type="" class="form-control" name="" value="johnwich@buba.com">
</div>
</div>
<div class="col-lg-6">
<div class="form-group">
<label>Default Hospital Address</label>
<textarea class="form-control" name="" rows="2" value="">45 East Block NY</textarea>
<a href="" class="sml-btn mt-3"><i class="fa fa-plus"></i> Add More Address</a>
</div>
<div class="form-group">
<label>Default Hospital Department</label>
<input type="" class="form-control" name="" value="OPD">
<a href="" class="sml-btn mt-3"><i class="fa fa-plus"></i> Add More Department</a>
</div>
</div>
</form>
</div>
<div class="modal-footer">
<a href="" class="btn btn-secondary" data-dismiss="modal">Cancel</a>
<a href="" class="btn btn-primary">Submit</a>
</div>
</div>
</div>
</div>
<!-- Kit Details Modal -->
<div class="modal fade bigModal" id="kitDetails" tabindex="-1" role="dialog" aria-labelledby="" aria-hidden="true">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="">Kit Details</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<table class="table">
<thead>
<tr>
<th>Product Code</th>
<th>Product Name</th>
<th>Qty</th>
</tr>
</thead>
<tbody>
<tr>
<td>M04 S0001</td>
<td>RTS Lesser MTP Instrument Kit - Size 1-3</td>
<td>2</td>
</tr>
<tr>
<td>M04 S0001</td>
<td>RTS Lesser MTP Implant Size 1</td>
<td>1</td>
</tr>
<tr>
<td>M04 S0001</td>
<td>RTS Lesser MTP Instrument Kit - Size 1-3</td>
<td>2</td>
</tr>
</tbody>
</table>
</div>
<div class="modal-footer">
<a href="" class="btn btn-secondary" data-dismiss="modal">Close</a>
</div>
</div>
</div>
</div>
<?php include("footer.php");?>
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</body>
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