[% # INCLUDE dumper.tt dump = params %]
[% # PROCESS dumper.tt dump = errs %]
<div class="container">
<div class="row">
<a name="top">
<img src="/images/logo.jpg" title="LCC Logo"
border="0" align="right" alt="LCC Logo"/>
</a>
</div>
<div class="row">
<!-- Form Name -->
<legend>HMDS Request Form</legend>
<h4><a href="#" id="is_trial">Request IS for clinical trial</a></h4>
<div id="trial-content" style="display: none;">
<p class="text-warning indent">
Please use specific clinical trial request form.
</p>
</div>
<h4><a href="#" id="non_trial">Request is NOT for clinical trial</a></h4>
<div id="non-trial-content" class="indent" [% # auto-open if form submission:
UNLESS params.size %]style="display: none"[% END %]>
<form class="form-horizontal" action="/" method="post">
<fieldset>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="last_name">Last name</label>
<div class="col-md-4">
[% errs.last_name %]
<input id="last_name" name="last_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.last_name %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="first_name">First name</label>
<div class="col-md-4">
[% errs.first_name %]
<input id="first_name" name="first_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.first_name %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="textinput">Date of Birth</label>
<div class="col-md-4">
[% errs.day OR errs.month OR errs.year %]
[% INCLUDE dateselect.tt %]
</div>
</div>
<!-- Multiple Radios (inline) -->
<div class="form-group">
<label class="col-md-2 control-label" for="radios">Gender</label>
<div class="col-md-2">
[% errs.gender %]
<label class="radio-inline" for="gender-0">
<input name="gender" id="gender-0" value="M" type="radio"
[% 'checked' IF params.gender.match('M') %]>M
</label>
<label class="radio-inline" for="gender-1">
<input name="gender" id="gender-1" value="F" type="radio"
[% 'checked' IF params.gender.match('F') %]>F
</label>
<label class="radio-inline" for="gender-2">
<input name="gender" id="gender-2" value="U" type="radio"
[% 'checked' IF params.gender.match('U') %]>U
</label>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="nhs_number">NHS number</label>
<div class="col-md-4">
[% errs.nhs_number %]
<input id="nhs_number" name="nhs_number" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.nhs_number %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="unit_number">
Patient/unit number
</label>
<div class="col-md-4">
[% errs.patient_number %]
<input id="unit_number" name="unit_number" placeholder="optional field"
class="form-control input-md" type="text"
value="[% params.patient_number %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="location">Location</label>
<div class="col-md-4">
[% errs.location %]
<input id="location" name="location" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.location %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="referrer">Referrer</label>
<div class="col-md-4">
[% errs.referrer %]
<input id="referrer" name="referrer" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.referrer %]">
</div>
</div>
<!-- Button -->
<div class="col-sm-offset-5 control-group">
<label class="control-label" for="submit"></label>
<div class="controls">
<button id="submit" name="submit"
class="btn btn-primary">Validate</button>
</div>
</div>
</fieldset>
</form>
</div>
</div>
<script type="text/javascript">
$('#is_trial').click(function() {
$('#trial-content').slideToggle('fast', function() {
// ok
});
return false;
});
$('#non_trial').click(function() {
$('#non-trial-content').slideToggle('fast', function() {
// ok
});
return false;
});
</script>