43 lines
1.8 KiB
PHP
43 lines
1.8 KiB
PHP
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<form action="" name="perjalanan_penyakit" method="post" id="perjalanan_penyakit">
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<input type="hidden" name="id_admission" value="<?php echo $id_admission;?>" />
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<input type="hidden" name="nomr" value="<?php echo $nomr;?>" />
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<input type="hidden" name="noruang" value="<?php echo $noruang;?>" />
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<fieldset class="fieldset">
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<label class="col-form-label col-sm-12 pt-0" style="text-align:center"><h5>KONSULTASI</h5></label>
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<div class="row">
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<fieldset class="form-group">
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<div class="row">
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<div class="col-sm-6">
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Tanggal</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="text" name="tanggal" cols="60" rows="5" class="form-control text" value="<?php echo date("d/m/Y"); ?>" readonly>
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</div>
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</div>
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</div>
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<div class="col-sm-6">
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right">Konsultasi</label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<textarea name="konsultasi" cols="60" rows="5" class="form-control text"></textarea>
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</div>
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</div>
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<div class="form-group row">
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<label class="col-form-label col-sm-4 pt-0" style="text-align:right"></label>
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<div class="col-sm-8 pt-0" style="text-align:left">
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<input type="submit" name="simpanf7" value="Simpan" class="btn btn-primary text"/>
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</div>
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</div>
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</div>
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</div>
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</fieldset>
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</div>
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</fieldset>
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<div id="valid_perjalanan_penyakit" >
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<?php include("save_perjalanan_penyakit.php"); ?>
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</div>
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</form>
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