<?php

/**
 * @author James P. Zimmerman II
 */

?>

<div id="developerMenu">
<div class="breadcrumbs">
    <?php   echo $this->navigation()->breadcrumbs()->setLinkLast( true )->setMinDepth( 0 )->render(); ?>
    </div>
</div>
<div style="clear:both;"></div>

<script type="text/javascript">
<!--//
$(document).ready(function() {
    // autotab
    $('#zip').autotab({ target: 'primaryPhone1', format: 'numeric', previous: 'state' });
    $('#primaryPhone1').autotab({ target: 'primaryPhone2', format: 'numeric', previous: 'zip' });
    $('#primaryPhone2').autotab({ target: 'primaryPhone3', format: 'numeric', previous: 'primaryPhone1' });
    $('#primaryPhone3').autotab({ target: 'secondaryPhone1', format: 'numeric', previous: 'primaryPhone2' });
    $('#secondaryPhone1').autotab({ target: 'secondaryPhone2', format: 'numeric', previous: 'primaryPhone3' });
    $('#secondaryPhone2').autotab({ target: 'secondaryPhone3', format: 'numeric', previous: 'secondaryPhone1' });
    $('#secondaryPhone3').autotab({ target: 'billingq', format: 'numeric', previous: 'secondaryPhone2' });

    // formatting hints
});
//-->
</script>
<form action="" method="post" accept-charset="utf-8">
    <?php
    if ($this->form->getMessages ()) {
        print ($this->partial ( '/partials/form_errors.phtml', array ('form' => $this->form ) )) ;
    }
    ?>
<div class="column1">
    <h3 class="currentInfoNewAdd"><?php echo $this->translate->_ ( 'Registration' ); ?></h3>
    <table id="addFormTable1">
    <tr class="even">
        <td><label for="email"><?=$this->form->email->getLabel ();?>:</label></td>
        <td><?=$this->form->email;?></td>
     </tr>
    <tr class="odd">
        <td><label for="password"><?=$this->form->password->getLabel ();?>:</label></td>
        <td><?=$this->form->password;?></td>
    </tr>
    <tr class="even">
        <td><label for="passwordConfirm"><?=$this->form->passwordConfirm->getLabel ();?>:</label></td>
        <td><?=$this->form->passwordConfirm;?></td>
    </tr>
</table>
<h3><?php echo $this->translate->_ ( 'System' ); ?></h3>
<table id="addFormTable2">
    <tr class="even">
        <td><label for="role"><?=$this->form->role->getLabel ();?>:</label></td>
        <td><?=$this->form->role;?></td>
    </tr>
    <tr class="odd">
        <td><label for="title"><?=$this->form->title->getLabel ();?><?php echo $this->translate ( '(employees only):' );?></label></td>
        <td><?=$this->form->title;?></td>
    </tr>
    <tr class="even">
        <td><label for="npi"><?=$this->form->npi->getLabel ();?><?php echo $this->translate ( '(doctors req/nurse opt)' );?>:</label></td>
        <td><?=$this->form->npi;?></td>
    </tr>
</table>
<h3><?php echo $this->translate ( 'Sitekey' );?></h3>
<ul class="sitekeyList">
   <?php foreach ( $this->form->sitekey->options as $key => $val ) :?>
      <li>
          <label>
              <input type="radio" value="<?=$key;?>"name="sitekey" id="<?=$key;?>" />
              <img src="<?=$this->sitekey_img_path . $val;?> " />
          </label>
      </li>
      <?php endforeach;?>
  </ul>
<div style="clear:both;"></div>
<table class="addFormTable5">
    <tr class="even">
        <td><label for="<?=$this->form->phrase->getLabel ();?>"><?=$this->form->phrase->getLabel ();?>:</label></td>
        <td><?=$this->form->phrase;?> </td>
    </tr>
 </table>
</div>
<div class="column2">
    <h3><?php echo $this->translate->_ ( 'Personal Information' ); ?></h3>
    <table id="addFormTable3">
        <tr class="odd">
            <td><label for="prefix"><?=$this->form->prefix->getLabel ();?>:</label></td>
            <td><?=$this->form->prefix;?></td>
        </tr>
        <tr class="even">
            <td><label for="firstName"><?=$this->form->firstName->getLabel ();?>:</label></td>
            <td><?=$this->form->firstName;?></td>
        </tr>
        <tr class="odd">
            <td><label for="lastName"><?=$this->form->lastName->getLabel ();?>:</label></td>
            <td><?=$this->form->lastName;?></td>
        </tr>
        <tr class="even">
            <td><label for="suffix"><?=$this->form->suffix->getLabel ();?>:</label></td>
            <td><?=$this->form->suffix;?></td>
        </tr>
        <tr class="odd">
            <td><label for="dob"><?php echo $this->translate ( 'Date of Birth' ); ?></label></td>
            <td><?=$this->form->dobMonth;?>&nbsp;/&nbsp;<?=$this->form->dobDay;?>&nbsp;/&nbsp;<?=$this->form->dobYear;?></td>
        </tr>
        <tr class="even">
            <td><label for="gender"><?=$this->form->gender->getLabel ();?>:</label></td>
            <td><?=$this->form->gender;?></td>
        </tr>
        <tr class="odd">
            <td><label for="Dependants"><?=$this->form->dependants->getLabel ();?>:</label></td>
            <td><?=$this->form->dependants;?><?php echo $this->translate ( 'Minors and Adults' );?></td>
        </tr>
    </table>

    <h3><?php echo $this->translate->_ ( 'Registration' );?></h3>
    <table id="addFormTable4">
        <tr class="odd"><td><?php echo $this->translate ('Current Residence (Patients Only)'); ?></td><td></td></tr>
            <tr class="even">
                <td><label for="address"><?=$this->form->address->getLabel ();?>: </label></td>
                <td><?=$this->form->address;?></td>
            </tr>
            <tr class="odd">
                <td><label for="city"><?=$this->form->city->getLabel ();?>: </label></td>
                <td><?=$this->form->city;?></td>
            </tr>
            <tr class="even">
                <td><label for="state"><?=$this->form->state->getLabel ();?>: </label></td>
                <td><?=$this->form->state;?></td>
            </tr>
            <tr class="odd">
                <td><label for="zip"><?=$this->form->zip->getLabel ();?>: </label></td>
                <td><?=$this->form->zip;?></td>
            </tr>
            <tr class="even">
                <td><label for="primaryPhone1"><?php
                echo $this->translate ( 'Primary Phone' ); ?>:</label></td>
                <td><?=$this->form->primaryPhone1;?>&nbsp;-&nbsp;<?=$this->form->primaryPhone2;?>&nbsp;-&nbsp;<?=$this->form->primaryPhone3;?></td>
            </tr>
            <tr class="odd">
                <td><label for="secondaryPhone1"><?php echo $this->translate ( 'Secondary Phone' );?>: </label></td>
                <td><?=$this->form->secondaryPhone1;?>&nbsp;-&nbsp;<?=$this->form->secondaryPhone2;?>&nbsp;-&nbsp;<?=$this->form->secondaryPhone3;?></td>
            </tr>
            <tr class="even">
                <!-- added needs intergration to db replacing personal info tab in med history -->
                <td><label for="billingq"><?=$this->form->billingq->getLabel ();?>: </label></td>
                <td><?=$this->form->billingq;?></td>
            </tr>
    </table>
</div>
<div class="formControls"><input type="submit"
    value="<?php
    echo $this->translate ( 'Submit' );
    ?>" /></div>
</form>