<div class="modal fade insert_frm4" id="modal-report4" 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-title4">Add Patient</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-form4" novalidate="novalidate" method="POST" enctype="multipart/form-data"
                    autocomplete="off" action="">
                    <div class="row">
                        <input type="hidden" name="action2" id="action2" value="UpdateQueue">
                        <input type="hidden" name="id2" id="id2" value="">
                        
                        <input type="hidden" name="PageVal" id="PageVal2" 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="Mrd_No2" name="MrdNo2" placeholder="" readonly>
                            </div>
                        </div>

                        <div class="col-sm-4">
                            <div class="form-group">
                                <label class="floating-label" for="Name">Patient Name <span
                                        class="text-danger">*</span></label>
                                <input type="text" class="form-control" id="PatientName2" name="PatientName2" placeholder="" readonly>
                            </div>
                        </div>
                        
                        <div class="col-sm-3">
                            <div class="form-group">
                                <label class="floating-label" for="gender">Gender <span
                                        class="text-danger">*</span></label>
                                <select class="form-control" id="Gender2" name="Gender2" 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-3">
                            <div class="form-group">
                                <label class="floating-label" for="Phone">Age <span class="text-danger">*</span></label>
                                <input type="text" class="form-control" name="Age2" id="Age2" placeholder="" required>
                            </div>
                        </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="Amount2" id="Fees2"
                                        onKeyPress="return isNumberKey(event)" value="">
                                  
                             
                                <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="PayMode2" name="PayMode2">
                                
                                    <option value="Cash" selected="">Cash</option>
                                    
                                </select>
                            </div>
                        </div>

                        <div class="col-sm-2">
                            <div class="form-group">
                                <label class="floating-label" for="gender">User <span
                                        class="text-danger">*</span></label>
                                <select class="form-control txtbold"
                            style="width: 100%;height:35px;" name="Createdby2"
                            id="Createdby2" disabled>

                            <?php $__currentLoopData = $userList; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $result): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                            <option value="<?php echo e($result->id); ?>"><?php echo e($result->Name); ?></option>
                            <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                        </select>
                            </div>
                        </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="Consultant2" name="Consultant2" disabled>
                                    <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-12">
                            <button class="btn btn-primary" name="submit" type="submit" id="submit4">Submit</button>
                            <button class="btn btn-danger" type="reset">Clear</button>
                        </div>
                    </div>
                </form>
            </div>
        </div>
    </div>
</div><?php /**PATH D:\Projects\Sidhha_Tech\st_projects\Laravel\deshmukh_hosp\resources\views/opd/incqueuepatient.blade.php ENDPATH**/ ?>