mc.html

<!DOCTYPE html>
<html lang="en">

<head>
    <meta charset="UTF-8">
    <meta name="viewport" content="width=device-width, initial-scale=1.0">
    <meta http-equiv="X-UA-Compatible" content="ie=edge">
    <title>Farrer Park Hospital Discharge eForms</title>
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    <link rel="stylesheet" type="text/css" href="asset/css/style.css">
    <script>
        $(function() {
            $("#unfit_duty_from").datepicker({
                dateFormat: 'dd/mm/yy',
                // minDate: 0,
                // maxDate: "+1M +10D"
            });
            $("#unfit_duty_to").datepicker({
                dateFormat: 'dd/mm/yy',
                // minDate: 0,
                // maxDate: "+1M +10D"
            });
            $("#date_from").datepicker({
                dateFormat: 'dd/mm/yy',
                // minDate: 0,
                // maxDate: "+1M +10D"
            });
            $("#date_to").datepicker({
                dateFormat: 'dd/mm/yy',
                // minDate: 0,
                // maxDate: "+1M +10D"
            });
        });
    </script>
</head>

<body>
    <div class="container-fluid">
        <header>
            <div id="top_navbar">
                <div class='logo'>
                    <a href="dashboard.html"><img src='asset/img/logo.jpg'></a>
                </div>
                <div class='logged_user'>

                    <span>
                        Welcome , Dr. Chiew Kim Huat Richard.   <br>
                        Your last login was on 10 Nov 2019 12:01pm
                    </span>

                    <button type='button' class='btn logout'>Logout</button>

                </div>
            </div>
        </header>
        <div class="clear_fix"></div>
        <div class="row">
            <div class="col-md-12 main-content">
                <ul class="nav nav-tabs" id="myTab" role="tablist">
                    <li class="nav-item">
                        <a class="nav-link active" id="Recent-tab" data-toggle="tab" href="#Recent" role="tab" aria-controls="Recent" aria-selected="true">Recent</a>
                    </li>
                    <li class="nav-item">
                        <a class="nav-link" id="Archives-tab" data-toggle="tab" href="#Archives" role="tab" aria-controls="Archives" aria-selected="false">Archives</a>
                    </li>
                    <li class="nav-item">
                        <a class="nav-link" id="Reports-tab" data-toggle="tab" href="#Reports" role="tab" aria-controls="Reports" aria-selected="false">Reports</a>
                    </li>
                </ul>
                <div class="tab-content" id="myTabContent">
                    <div class="tab-pane show active" id="Recent" role="tabpanel" aria-labelledby="Recent-tab">
                        <h3 class='page_title center'>Discharge Summary</h3>

                        <div class="container-fluid">
                            <div class="row">
                                <div class="col-sm-6">

                                </div>
                                <div class="col-sm-3">
                                    <label>Serial Number :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='p_name'></label>
                                </div>
                                <div class="col-sm-6">

                                </div>
                                <div class="col-sm-3">
                                    <label>Date/Time :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='date'>10/11/2019</label>
                                </div>
                                <div class="m_15"></div>
                                <div class="m_15"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label>Name :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='p_name'></label>
                                </div>
                                <div class="col-sm-3">
                                    <label>Medical Record No :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='p_medical_no'></label>
                                </div>
                                <div class="col-sm-3">
                                    <label>Date of Birth :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='p_dob'></label>
                                </div>
                                <div class="col-sm-3">
                                    <label>Patient Status :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='p_status'>Discharged</label>
                                </div>
                                <div class="col-sm-3">
                                    <label>Attending Doctor :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='attend_doctor'>Dr. Chiew Kim Huat Richard</label>
                                </div>

                                <div class="col-sm-3">
                                    <label>Patient Acccount No. :</label>
                                </div>
                                <div class="col-sm-3">
                                    <label class='acc_no'></label>
                                </div>

                                <div class="col-sm-3">
                                    <label>PType of Medical Leave Granted :</label>
                                </div>
                                <div class="col-sm-3">
                                    <select class="form-control" name='type_mc'>
                                            <option>Hospitalisation Leave</option>
                                            <option>...</option>
                                            <option>...</option>
                                        </select>
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label><span style='color:red'>*</span>Number of Days :</label>
                                </div>
                                <div class="col-sm-3">
                                    <input type="number" class="form-control" name='no_of_days'>
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label><span style='color:red'>*</span>Unfit for Duty From :</label>
                                </div>
                                <div class="col-sm-3">
                                    <input class='form-control' type="text" id="unfit_duty_from" name='unfit_duty_from' placeholder="20/11/2019">
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label><span style='color:red'>*</span>Unfit for Duty To :</label>
                                </div>
                                <div class="col-sm-3">
                                    <input class='form-control' type="text" id="unfit_duty_to" name='unfit_duty_to' placeholder="22/11/2019">
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label>Fit For Light Duty:</label>
                                </div>
                                <div class="col-sm-3">
                                    <select name="light_duty" id="" class="form-control">
                                      <option value="yes">Yes</option>
                                      <option value='no'>No</option>
                                    </select>
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label>Date From :</label>
                                </div>
                                <div class="col-sm-3">
                                    <input class='form-control' type="text" id="date_from" name='date_from' placeholder="28/11/2019">
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>
                                <div class="col-sm-3">
                                    <label>Date To :</label>
                                </div>
                                <div class="col-sm-3">
                                    <input class='form-control' type="text" id="date_to" name='date_to' placeholder="28/11/2019">
                                </div>
                                <div class="col-sm-6"></div>
                                <div class="m_15"></div>

                                <!-- section2 -->
                                <h4 class='section_title'>Activities Exempted</h4>
                                <div class="col-sm-12">
                                    <textarea rows="10" name="activities_examptede" style='width:100%;'></textarea>
                                </div>
                                <div class='m_15'></div>
                                <h4 class='section_title'>Covering Doctor</h4>
                                <div class='m_15'></div>
                                <div class='m_15'></div>
                                <div class='m_15'></div>
                                <div class="col-sm-3">
                                    Doctor Name :
                                </div>
                                <div class="col-sm-9">
                                    Dr Chong Kwan Yin
                                </div>
                                <div class="col-sm-3">
                                    Doctor MCR No :
                                </div>
                                <div class="col-sm-9">
                                    03792C
                                </div>
                                <div class='m_15'></div>
                                <div class='m_15'></div>
                                <div class='m_15'></div>


                                <div class="col-sm-9">

                                </div>
                                <div class="col-sm-3">
                                    <div class="btn-group mc_actions" role="group" aria-label="Basic example">

                                        <button type="button" class="btn footer_btn_save">Submit</button>
                                        <button type="button" class="btn footer_btn_save" onClick="window.print()">Print</button>

                                    </div>
                                </div>
                                <div class='m_15'></div>
                            </div>
                        </div>


                    </div>
                    <div class="tab-pane fade" id="Archives" role="tabpanel" aria-labelledby="Archives-tab">Archives tab</div>
                    <div class="tab-pane fade" id="Reports" role="tabpanel" aria-labelledby="Reports-tab">Reports tab</div>

                </div>
            </div>

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</body>

</html>