Untitled

<?php
	include("header.php");
?>
<style>
	#patient_photo {
		text-align: center;
	}
</style>
</head>
<body>
	<ul class="nav nav-tabs">
		<li class="active">
			<a href="#">Patient Information</a>
		</li>
		<li><a href="#">...</a></li>
		<li><a href="#">...</a></li>
	</ul>
	<div class="container well">
		<form class="form-horizontal">
	    	<fieldset>
				<div id="legend" class="">
					<legend class="">Personal Information</legend>
				</div>

	    	<div class="row">
	    		<div class="span12">
					<div class="control-group" id="patient_photo">
						<!-- <label class="control-label">File Button</label> -->
						<img src="img/patient_photo.jpg" class="img-polaroid">
						<div class="controls">
							<input class="input-file" id="fileInput" type="file">
						</div>
					</div>
				</div>

	    		<div class="span6">
					<div class="control-group">
						<label class="control-label" for="input01">First Name</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="fname">
							<p class="help-block"></p>
						</div>
					</div>

			    	<div class="control-group">
						<label class="control-label" for="input01">Middle Name</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="mname">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label" for="input01">Last Name</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="lname">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label" for="input01">Preferred Name</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="pname">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label">Gender</label>
							<div class="controls">
							<label class="radio inline">
								<input type="radio" value="Male" name="group" checked="checked" id="male">
								Male
							</label>
							<label class="radio inline">
								<input type="radio" value="Female" name="group" id="female">
								Female
							</label>
						</div>
				    </div>

					<div class="control-group">
						<label class="control-label" for="input01">Birthdate</label>
						<div class="controls">
							<input type="text" class="input-xlarge" id="birthdate">
							<p class="help-block"></p>
						</div>
					</div>

				</div> <!-- end of first span -->

				<div class="span6">
					<div class="control-group">
						<label class="control-label" for="input01">Street Address</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="address">
							<p class="help-block"></p>
						</div>
					</div>

				    <div class="control-group">
						<label class="control-label" for="input01">City</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="city">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label" for="input01">ZIP</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="zip">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label" for="input01">Contact Number</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="contact">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label" for="input01">Email Address</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="email">
							<p class="help-block"></p>
						</div>
					</div>

					<div class="control-group">
						<label class="control-label" for="input01">Guardian</label>
						<div class="controls">
							<input type="text" placeholder="" class="input-xlarge" id="guardian">
							<p class="help-block"></p>
						</div>
					</div>
				</div> <!-- end of 2nd span -->

				<div class="span12">
					<input type="submit" class="btn btn-success" value="Save" onclick="save_information()"/>
					<input type="submit" class="btn btn-warning pull-right" value="Cancel"/>
	    		</div>
	    	</fieldset>
		</form>
		<script src="js/jquery-1.7.2.min.js"></script>
		<script src="js/jquery-ui-1.8.21.custom.min.js"></script>
		<script src="js/bootstrap.min.js"></script>
		<script>

			function save_information(){
				columns = {
					"fname" : $("#fname").val(),
					"mname" : $("#mname").val(),
					"lname" : $("#lname").val(),
					"pname" : $("#pname").val(),
					"gender" : $("#gender").val(),
					"address" : $("#address").val(),
					"city" : $("#city").val(),
					"zip" : $("#zip").val(),
					"birthdate" : $("#birthdate").val(),
					"email" : $("#email").val(),
					"guardian" : $("#guardian").val(),
					"action":"add_information"
				};
				$.ajax({
		            type: "POST",
		            data: columns,
		            url: "patient_information_ajax.php",
		            success:function(response){
		            	alert(response);
		      		}
		        });
			}

		</script>
<?php
	include("footer.php");
?>