<!-- BEGIN patient/default.tt -->
[% META title = 'Registration » Register New Patient' -%]
<h2 class="header">Register new patient</h2>
[% # PROCESS dumper.tt dump = maybe_duplicate %]
[% js_new_patient_dfv_js %]
[% IF dfv_errors %]
<p class="error">[% c.cfg('msg').dfv_errors %]</p>
[% IF error_patient_id %]
<ul><li>[% c.cfg('msg').require_one %]</li></ul>
[% END %]
[% END %]
[% PROCESS site/autosuggest.tt %]
<script type="text/javascript">
jQuery( function() {
$("#is_valid_date_day").Watermark("dd");
$("#is_valid_date_month").Watermark("mm");
$("#is_valid_date_year").Watermark("yyyy");
} );
</script>
<div id="bad_patient"></div>
<form action="[% app_url %]/patient/add_new" method="post" name="add_new" id="add_new"
[% js_new_patient_onsubmit %]>
[% PROCESS patient/pas.tt IF pas_query %]
[% PROCESS patient/pds.tt IF pds_query %]
[% PROCESS patient/duplicate.tt IF maybe_duplicate %]
<div class="indent">
<table>
<tr>
<td class="label">Last Name:</td>
<td class="content">
<input class="field" type="text" name="last_name" size="30"
id="last_name" [% site.html.on_focus %]
value="[% c.query.param('last_name') %]" />
[% error_last_name %]
</td>
</tr>
<tr>
<td class="label">First Name:</td>
<td class="content">
<input class="field" type="text" name="first_name" size="30"
id="first_name" [% site.html.on_focus %]
value="[% c.query.param('first_name') %]" />
[% error_first_name %]
</td>
</tr>
<tr>
<td class="label">Middle Name(s):</td>
<td class="content">
<input class="field" type="text" name="middle_name" size="30"
value="[% c.query.param('middle_name') %]" [% site.html.on_focus %]/>
[% error_middle_name %]
</td>
</tr>
<tr>
[% SET class = error_patient_id ? 'input_error' : 'field' %]
<td class="label">NHS No:</td>
<td class="content">
<input class="[% class %]" type="text" name="nhs_number" size="12"
id="is_valid_and_unique_nhsno" value="[% c.query.param('nhs_number') %]"
[% IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(['is_valid_and_unique_nhsno'], ['bad_nhsno']); return true;"
[% END %]
[% site.html.on_focus %] />
[% error_nhs_number %]
<span class="ajax_error"><em id="bad_nhsno"></em></span>
</td>
</tr>
[% BLOCK validate_date; IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(
['is_valid_date_day','is_valid_date_month','is_valid_date_year'],
['bad_date']
); return true;"
[% END; END %]
<tr>
[% SET class = error_year || error_day ? 'input_error' : 'field' %]
<td class="label">DoB:</td>
<td class="content">
<input type="text" name="day" size="2" id="is_valid_date_day"
value="[% c.query.param('day') %]"
[% PROCESS validate_date %] maxlength="2" class="[% class %]"
[% site.html.on_focus %] />
<input type="text" name="month" size="2" id="is_valid_date_month"
value="[% c.query.param('month') %]"
[% PROCESS validate_date %] maxlength="2" class="[% class %]"
[% site.html.on_focus %] />
<input type="text" name="year" size="4" id="is_valid_date_year"
value="[% c.query.param('year') %]"
[% PROCESS validate_date %] maxlength="4" class="[% class %]"
[% site.html.on_focus %] />
[% UNLESS error_day || error_year # set if date invalid %]
<span class="ajax_error"><em id="bad_date"></em></span>
[% END %]
[% error_day || error_year # set if date invalid %]
</td>
</tr>
<tr>
<td class="label">Gender:</td>
<td class="content">
[% FOREACH entry IN ['M','F','U'] %]
<input type="radio" value="[% entry %]" name="gender"
[% IF entry.match(c.query.param('gender')) %]checked[% END %] />
[% entry %]
[% END %]
[% error_gender %]
</td>
</tr>
<tr>
<td class="label">Source:</td>
<td class="search_bar">
<input style="width: 300px" type="text" name="_source" id="location_name"
value="[% c.query.param('location_name') %]" />
<input type="hidden" id="source_id" name="referral_source_id"
value="[% c.query.param('location_id') %]" >
[% IF error_referral_source_id %]
[% error_referral_source_id %]
[% ELSE %]
[ <a href="[% app_url %]/config/referral-sources">new</a> ]
[% END %]
</td>
</tr>
[% BLOCK validate_patient; IF c.cfg('use_cgi_ajax') %]
onChange="do_ajax(
['last_name', 'first_name', 'is_valid_nhsno', 'is_valid_date_day',
'is_valid_date_month', 'is_valid_date_year', 'unit_number'],
['bad_patient']); return true;"
[% END; END %]
<tr>
[% SET class = error_patient_id ? 'input_error' : 'field' %]
<td class="label">Unit number:</td>
<td class="content">
<input class="[% class %]" type="text" name="unit_number" size="12"
id="unit_number" [% site.html.on_focus %]
[% # PROCESS validate_patient # doesn't work if ! unit_no %]
value="[% c.query.param('unit_number') %]" />
[% error_unit_number %]
</td>
</tr>
</table>
</div>
[% IF c.query.param('_skip_pas') # flag to skip pas query if already done %]
<input type="hidden" name="_pas_confirmed" value="1" />
[% END %]
[% IF nhs_number_duplicate # set in duplicate.tt %]
<p class="error">
Duplicate NHS number must be resolved before record can be submitted.
</p>
[% ELSE %]
<p class="center">
[% site.html.submit %]
[% site.html.reset %]
</p>
[% END %]
</form>
<p>[% site.html.back_button %]</p>
<!-- END patient/default.tt -->