Template
person-programmer
77 lines
4.2 KiB
PHP
77 lines
4.2 KiB
PHP
@extends('layouts.admin_master')
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@section('content')
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<main>
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<div class="container">
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<div class="row justify-content-center">
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<div class="col-lg-7">
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<div class="card shadow-lg border-0 rounded-lg mt-5">
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<div class="card-header"><h1 class="text-center font-weight-light my-4"><b>Tambahkan Pasien</b></h1></div>
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<div class="card-body">
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<form method="POST" action="{{ url('/insert-customer') }}" enctype="multipart/form-data">
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@csrf
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<div class="form-check">
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<div class="col-md-20">
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<div class="form-group">
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<label class="small mb-1" for="inputFirstName">Tipe Pasien</label>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="tipepasien" id="flexRadioDefault1">
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<label class="form-check-label" for="flexRadioDefault1">
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Pasien Baru
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</label>
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</div>
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<div class="form-check">
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<input class="form-check-input" type="radio" name="tipepasien" id="flexRadioDefault1">
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<label class="form-check-label" for="flexRadioDefault1">
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Pasien Lama
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</label>
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</div>
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<div class="col-md-20">
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<div class="form-group">
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<label class="small mb-1" for="inputFirstName">Nama Pasien</label>
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<input class="form-control py-4" name="name" type="text" placeholder="" />
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</div>
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</div>
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<div class="col-md-20">
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<div class="form-group">
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<label class="small mb-1" for="inputFirstName">Email</label>
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<input class="form-control py-4" name="email" type="text" placeholder="" />
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</div>
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</div>
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<div class="col-md-20">
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<div class="form-group">
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<label class="small mb-1" for="inputLastName">No BPJS</label>
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<input class="form-control py-4" name="company" type="text" placeholder="" />
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</div>
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</div>
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<div class="col-md-20">
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<div class="form-group">
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<label class="small mb-1" for="inputLastName">Alamat</label>
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<input class="form-control py-4" name="address" type="text" placeholder="" />
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</div>
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</div>
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<div class="col-md-20">
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<div class="form-group">
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<label class="small mb-1" for="inputLastName">No Telepon</label>
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<input class="form-control py-4" name="phone" type="text" placeholder="" />
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</div>
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</div>
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</div>
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<div class="form-group mt-4 mb-0"><button class="btn btn-primary btn-block">Submit</button></div>
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</form>
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</div>
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</div>
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</div>
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</div>
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</div>
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</main>
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@endsection |