[% user = session.user; # INCLUDE dumper.tt dump = session %]
<table class="table table-striped table-condensed">
<!--
<tr>
<td>NHS number</td>
<td>[% user.nhs_number %]</td>
</tr>
-->
<tr>
<td>Date of Birth</td>
<td>[% user.dob.strftime('%d.%b.%Y') %]</td>
</tr>
<tr>
<td>Address</td>
<td>[% user.address %], [% user.post_code %]</td>
</tr>
<tr>
<td>Contact number</td>
<td>[% user.contact_number %]</td>
</tr>
<tr>
<td>Email</td>
<td>[% user.email %]</td>
</tr>
<tr>
<td>Your GP</td>
<td>[% user.gp %], [% user.practice %]</td>
</tr>
</table>
<div class="panel-group" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-warning">
<div class="panel-heading" role="tab" id="panel-heading">
<div class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#patientdetails" aria-expanded="false" aria-controls="patientdetails">
If any of the above details are incorrect, please click here
</a>
</div>
</div>
<div id="patientdetails" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="panel-heading">
<div class="panel-body">
[% # INCLUDE dumper.tt dump = session.user %]
<form action="javascript:;" method="post" id="patient-details">
<div class="form-group" id="fist_name-group">
<label for="first_name">First name</label>
<input type="text" class="form-control" id="first_name"
name="first_name" value="[% user.first_name.ucfirst %]">
</div>
<div class="form-group" id="last_name-group">
<label for="last_name">Last name</label>
<input type="text" class="form-control" id="last_name"
name="last_name" value="[% user.last_name.upper %]">
</div>
<div class="form-group" id="dob-group">
<label for="dob">Date of birth</label>
<input type="text" class="form-control" id="dob"
name="dob" value="[% user.dob.strftime('%d %b %Y') %]">
</div>
<div class="form-group" id="contact_number-group">
<label for="contact_number">Contact number</label>
<input type="text" class="form-control" id="contact_number"
name="contact_number" value="[% user.contact_number %]">
</div>
<div class="form-group" id="email-group">
<label for="email">Email address</label>
<input type="email" class="form-control" id="email"
name="email" value="[% user.email %]">
</div>
<div class="form-group" id="address-group">
<label for="address">Postal address</label>
<input type="text" class="form-control" id="address"
name="address" value="[% user.address %], [% user.post_code %]">
</div>
<div class="form-group" id="practice-group">
<label for="practice">GP details</label>
<input type="text" class="form-control" id="practice"
name="practice" value="[% user.gp %], [% user.practice %]">
</div>
<div class="form-group" id="password-group">
<label for="password">Your password</label>
<input type="password" class="form-control" id="password"
required name="password" placeholder="password">
</div>
<button type="submit" class="btn btn-success">Submit
<span class="fa fa-arrow-right"></span>
</button>
<div id="result"></div>
</form>
</div>
</div>
</div>
</div>