<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>&times;</span>
                </button>
            </div>

            <div class="modal-body">
                <form id="validation-form" novalidate method="POST" enctype="multipart/form-data"
                      autocomplete="off" action="">
                    <?php echo csrf_field(); ?>

                    <input type="hidden" name="action" id="action" value="SaveQueue">
                    <input type="hidden" name="id" id="id">
                    <input type="hidden" name="PageVal" id="PageVal">

                    <div class="row">

    <!-- Row 1 -->
    <div class="col-md-2">
        <label class="floating-label">Mrd No *</label>
        <input type="text" class="form-control" id="MrdNo" name="Mrd_No" readonly>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Reg. Date *</label>
        <input type="date" class="form-control" id="RegDate" name="RegDate" value="<?php echo e(date('Y-m-d')); ?>">
    </div>

    <div class="col-md-2">
        <label class="floating-label">&nbsp;</label>
        <div>
            <input type="checkbox" id="ForVaccination" name="ForVaccination">
            <label class="text-danger font-weight-bold">For Vaccination</label>
        </div>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Suffix</label>
        <select class="form-control" id="Suffix" name="Suffix">
            <option value="">Select Suffix</option>
            <option>Mr.</option><option>Mrs.</option><option>Miss.</option><option>Master</option>
        </select>
    </div>

    <div class="col-md-2">
        <label class="floating-label">First Name *</label>
        <input type="text" class="form-control" id="Fname" name="Fname" required>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Middle Name</label>
        <input type="text" class="form-control" id="Mname" name="Mname">
    </div>


    <!-- Row 2 -->
    <div class="col-md-2">
        <label class="floating-label">Last Name *</label>
        <input type="text" class="form-control" id="Lname" name="Lname" required>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Gender *</label>
        <select class="form-control" id="Gender" name="Gender" required>
            <option value="">Select Gender</option>
            <option>Male</option><option>Female</option>
        </select>
    </div>

    <div class="col-md-2">
        <label class="floating-label">DOB</label>
        <input type="date" class="form-control" id="Dob" name="Dob" onchange="getAge(this.value)">
    </div>

    <div class="col-md-2">
        <label class="floating-label">Age *</label>
        <input type="text" class="form-control" id="Age" name="Age" required>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Weight</label>
        <input type="text" class="form-control" id="Weight" name="Weight">
    </div>

    <div class="col-md-2">
        <label class="floating-label">Height</label>
        <input type="text" class="form-control" id="Height" name="Height">
    </div>


    <!-- Row 3 -->
    <div class="col-md-2">
        <label class="floating-label">Temp.</label>
        <input type="text" class="form-control" id="Temp" name="Temp">
    </div>

    <div class="col-md-2">
        <label class="floating-label">Mobile1 *</label>
        <input type="text" class="form-control" id="Phone" name="Phone" required>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Mobile2</label>
        <input type="text" class="form-control" id="Phone2" name="Phone2">
    </div>

    <div class="col-md-2">
        <label class="floating-label">Phone No</label>
        <input type="text" class="form-control" id="PhoneNo" name="PhoneNo">
    </div>

    <div class="col-md-2">
        <label class="floating-label">Email ID</label>
        <input type="email" class="form-control" id="Email" name="Email">
    </div>

    <div class="col-md-2">
        <label class="floating-label">City</label>
        <input type="text" class="form-control" id="City" name="City">
    </div>


    <!-- Row 4 -->
    <div class="col-md-4">
        <label class="floating-label">Address</label>
        <textarea class="form-control" id="Address" name="Address"></textarea>
    </div>

    <div class="col-md-4">
        <label class="floating-label">Parent Occupation</label>
        <input type="text" class="form-control" id="ParentOcc" name="ParentOcc">
    </div>

    <div class="col-md-4">
        <label class="floating-label">State</label>
        <input type="text" class="form-control" id="State" name="State" value="Maharashtra">
    </div>


    <!-- Row 5 -->
    <div class="col-md-3">
        <label class="floating-label">Consultant Name *</label>
        <select class="form-control" id="Consultant" name="Consultant" required>
            <option value="">...</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-md-2">
        <label class="floating-label">Fees *</label>
        <div class="input-group">
            <span class="input-group-text">Rs.</span>
            <input type="text" class="form-control" id="Fees" name="Fees" required>
        </div>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Patient Type</label>
        <select class="form-control" id="PatientType" name="PatientType">
            <option value="">Select</option>
            <option>General</option><option>Vaccination</option><option>Emergency</option>
        </select>
    </div>

    <div class="col-md-2">
        <label class="floating-label">Code</label>
        <input type="text" class="form-control" id="Code" name="Code">
    </div>

    <div class="col-md-3">
        <label class="floating-label">Payment Mode *</label>
        <select class="form-control" id="PayMode" name="PayMode" required>
            <option value="Cash">Cash</option>
        </select>
    </div>


    <!-- Row 6 -->
    <div class="col-md-3">
        <label class="floating-label">Type</label>
        <select class="form-control" id="OpdType" name="OpdType">
            <option value="1">OPD</option>
            <option value="2">Appointment</option>
        </select>
    </div>

    <div class="col-md-9">
        <label class="floating-label">Referred By</label>
        <input type="text" class="form-control" id="RefBy" name="RefBy">
    </div>


    <!-- Buttons -->
    <div class="col-md-12 text-center mt-3">
        <button class="btn btn-primary" type="submit">SUBMIT</button>
        <button class="btn btn-warning" type="reset">CLEAR</button>
        <button class="btn btn-danger" type="button" onclick="clearBlankRecord()">CLEAR BLANK RECORD</button>
    </div>

</div>

                </form>
            </div>

        </div>
    </div>
</div>
<?php /**PATH C:\laragon\www\parijathosp\resources\views/opd/incnewpatient.blade.php ENDPATH**/ ?>