<div class="modal fade insert_frm" id="modal-report" tabindex="-1" role="dialog"
    aria-labelledby="myExtraLargeModalLabel" aria-hidden="true">
    <div class="modal-dialog" style="max-width: 70rem; ">
        <div class="modal-content">


            <div class="modal-header">
                <h5 class="modal-title">Add Patient 
                    <span style="padding-left: 10px;">
                    <button class="btn btn-success btn-sm mb-3 btn-round" onclick="viewOpdQueue()">
                        view OPD Queue</button></span></h5>
                <button type="button" class="close" data-dismiss="modal" aria-label="Close">
                    <span aria-hidden="true">&times;</span>
                </button>
            </div>
            <div class="modal-body">
                <form id="validation-form" novalidate="novalidate" method="POST" enctype="multipart/form-data"
                    autocomplete="off" action="">
                    <div class="row">
                        <input type="hidden" name="action" id="action" value="SaveQueue">
                        <input type="hidden" name="id" id="id" value="">
           
                        <input type="hidden" name="PageVal" id="PageVal" value="">
                        <?php echo csrf_field(); ?>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Name">Mrd No <span
                                        class="text-danger">*</span></label>
                                <input type="text" class="form-control" id="MrdNo" name="Mrd_No" value="" placeholder="" readonly>
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Sex">Suffix </label>
                                <select class="form-control" id="Suffix" name="Suffix" onchange="getGender(this.value)">
                                    <option value="" disabled="" selected="">Select Suffix</option>
                                    <option value="Mr.">Mr.</option>
                                    <option value="Mrs.">Mrs.</option>
                                    <option value="Miss.">Miss.</option>
                                    <option value="Master">Master</option>
                                    
                                </select>
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Name">First Name <span
                                        class="text-danger">*</span></label>
                                <input type="text" class="form-control" id="Fname" name="Fname" placeholder="" required>
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Name">Middle Name </label>
                                <input type="text" class="form-control" name="Mname" id="Mname" placeholder="">
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Name">Last Name <span
                                        class="text-danger">*</span></label>
                                <input type="text" class="form-control" name="Lname" id="Lname" placeholder="" required>
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="gender">Gender <span
                                        class="text-danger">*</span></label>
                                <select class="form-control" id="Gender" name="Gender" required>
                                    <option value="" disabled="" selected="">Select Gender</option>
                                    <option value="Male">Male</option>
                                    <option value="Female">Female</option>
                                </select>
                            </div>
                        </div>
                        <!-- <div class="col-sm-4">
                            <div class="form-group fill">
                                <label class="floating-label" for="Birth">Birth Date </label>
                                <input type="date" class="form-control" name="Dob" id="Dob"
                                    onchange="getAge(this.value);">
                            </div>
                        </div> -->
                        <div class="col-sm-1">
                            <div class="form-group">
                                <label class="floating-label" for="Phone">Age <span class="text-danger">*</span></label>
                                <input type="text" class="form-control" name="Age" id="Age" placeholder="" required>
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Phone">Mobile1 <span
                                    class="text-danger">*</span></label>
                                <input type="text" class="form-control" id="Phone" name="Phone" placeholder=""
                                    onKeyPress="return isNumberKey(event)" required>
                            </div>
                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="Phone">Mobile2</label>
                                <input type="text" class="form-control" id="Phone2" name="Phone2" placeholder=""
                                    onKeyPress="return isNumberKey(event)">
                            </div>
                        </div>
                       
                        <div class="col-sm-5">
                            <div class="form-group">
                                <label class="floating-label" for="Address">Address </label>
                                <textarea class="form-control" id="Address" name="Address" style="height: 35px;"></textarea>
                            </div>
                        </div>

                       
                            <div class="form-group col-md-2">
                                <label class="floating-label" for="gender">Type</label>
                                <select class="form-control" id="OpdType" name="OpdType">
                                   
                                    <option value="1" selected="">OPD</option>
                                    <option value="2">Appointment</option>
                                   
                                </select>
                            </div> 
                            <div class="form-group col-md-3">
                                <label class="floating-label" for="gender">Consultant Name <span
                                    class="text-danger">*</span></label>
                                <select class="form-control" id="Consultant" name="Consultant" required>
                                    <option value="" selected>...</option>
                                   <?php $__currentLoopData = $consultantList; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $consultant): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                                    <option value="<?php echo e($consultant->id); ?>"><?php echo e($consultant->Name); ?></option>
                                    <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                                   
                                   
                                </select>
                            </div> 
                        <div class="col-sm-2">
                            <label class="floating-label" for="Phone">Fees <span class="text-danger">*</span></label>
                            <div class="input-group">
                                <div class="input-group-prepend">
                                    <span class="input-group-text">Rs.</span>

                                </div>
                                <input type="text" list="Feeslist" class="form-control" name="Fees" id="Fees"
                                        onKeyPress="return isNumberKey(event)" value="" required >
                                  
                             
                                <div class="clearfix"></div>
                            </div>

                        </div>
                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="gender">Payment Mode <span
                                        class="text-danger">*</span></label>
                                <select class="form-control" id="PayMode" name="PayMode" required>
                                    <option value="" disabled="">Select Payment Mode</option>
                                    <option value="Cash" selected="">Cash</option>
                                    <!-- <option value="Coupon">Coupon</option>
                                    <option value="Mobile Payment">Mobile Payment</option> -->
                                </select>
                            </div>
                        </div>
                       
                        <div class="col-sm-5">
                            <div class="form-group">
                                <label class="floating-label" for="Phone">Referred by</label>
                                <input type="text" autocomplete="off" class="form-control" id="RefBy" name="RefBy" placeholder="">
                                <div id="autocomplete-list" class="autocomplete-list" style="display: none; position: absolute;"></div>
                            </div>
                        </div>
                        <div class="col-sm-12">
                            <button class="btn btn-primary" name="submit" type="submit" id="submit">Submit</button>
                            <button class="btn btn-danger" type="reset">Clear</button>
                            <button class="btn btn-danger" type="button" onclick="clearBlankRecord()" id="clearblank">Clear Blank Record</button>
                        </div>
                    </div>
                </form>
            </div>
        </div>
    </div>
</div><?php /**PATH D:\Projects\Sidhha_Tech\st_projects\Laravel\deshmukh_hosp\resources\views/opd/incnewpatient.blade.php ENDPATH**/ ?>