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  1. <?php
  2.  
  3. /**
  4.  * @author James P. Zimmerman II
  5.  */
  6.  
  7. ?>
  8.  
  9. <div id="developerMenu">
  10. <div class="breadcrumbs">
  11.     <?php   echo $this->navigation()->breadcrumbs()->setLinkLast( true )->setMinDepth( 0 )->render(); ?>
  12.     </div>
  13. </div>
  14. <div style="clear:both;"></div>
  15.  
  16. <script type="text/javascript">
  17. <!--//
  18. $(document).ready(function() {
  19.     // autotab
  20.     $('#zip').autotab({ target: 'primaryPhone1', format: 'numeric', previous: 'state' });
  21.     $('#primaryPhone1').autotab({ target: 'primaryPhone2', format: 'numeric', previous: 'zip' });
  22.     $('#primaryPhone2').autotab({ target: 'primaryPhone3', format: 'numeric', previous: 'primaryPhone1' });
  23.     $('#primaryPhone3').autotab({ target: 'secondaryPhone1', format: 'numeric', previous: 'primaryPhone2' });
  24.     $('#secondaryPhone1').autotab({ target: 'secondaryPhone2', format: 'numeric', previous: 'primaryPhone3' });
  25.     $('#secondaryPhone2').autotab({ target: 'secondaryPhone3', format: 'numeric', previous: 'secondaryPhone1' });
  26.     $('#secondaryPhone3').autotab({ target: 'billingq', format: 'numeric', previous: 'secondaryPhone2' });
  27.  
  28.     // formatting hints
  29. });
  30. //-->
  31. </script>
  32. <form action="" method="post" accept-charset="utf-8">
  33.     <?php
  34.     if ($this->form->getMessages ()) {
  35.         print ($this->partial ( '/partials/form_errors.phtml', array ('form' => $this->form ) )) ;
  36.     }
  37.     ?>
  38. <div class="column1">
  39.     <h3 class="currentInfoNewAdd"><?php echo $this->translate->_ ( 'Registration' ); ?></h3>
  40.     <table id="addFormTable1">
  41.     <tr class="even">
  42.         <td><label for="email"><?=$this->form->email->getLabel ();?>:</label></td>
  43.         <td><?=$this->form->email;?></td>
  44.      </tr>
  45.     <tr class="odd">
  46.         <td><label for="password"><?=$this->form->password->getLabel ();?>:</label></td>
  47.         <td><?=$this->form->password;?></td>
  48.     </tr>
  49.     <tr class="even">
  50.         <td><label for="passwordConfirm"><?=$this->form->passwordConfirm->getLabel ();?>:</label></td>
  51.         <td><?=$this->form->passwordConfirm;?></td>
  52.     </tr>
  53. </table>
  54. <h3><?php echo $this->translate->_ ( 'System' ); ?></h3>
  55. <table id="addFormTable2">
  56.     <tr class="even">
  57.         <td><label for="role"><?=$this->form->role->getLabel ();?>:</label></td>
  58.         <td><?=$this->form->role;?></td>
  59.     </tr>
  60.     <tr class="odd">
  61.         <td><label for="title"><?=$this->form->title->getLabel ();?><?php echo $this->translate ( '(employees only):' );?></label></td>
  62.         <td><?=$this->form->title;?></td>
  63.     </tr>
  64.     <tr class="even">
  65.         <td><label for="npi"><?=$this->form->npi->getLabel ();?><?php echo $this->translate ( '(doctors req/nurse opt)' );?>:</label></td>
  66.         <td><?=$this->form->npi;?></td>
  67.     </tr>
  68. </table>
  69. <h3><?php echo $this->translate ( 'Sitekey' );?></h3>
  70. <ul class="sitekeyList">
  71.    <?php foreach ( $this->form->sitekey->options as $key => $val ) :?>
  72.       <li>
  73.           <label>
  74.               <input type="radio" value="<?=$key;?>"name="sitekey" id="<?=$key;?>" />
  75.               <img src="<?=$this->sitekey_img_path . $val;?> " />
  76.           </label>
  77.       </li>
  78.       <?php endforeach;?>
  79.   </ul>
  80. <div style="clear:both;"></div>
  81. <table class="addFormTable5">
  82.     <tr class="even">
  83.         <td><label for="<?=$this->form->phrase->getLabel ();?>"><?=$this->form->phrase->getLabel ();?>:</label></td>
  84.         <td><?=$this->form->phrase;?> </td>
  85.     </tr>
  86.  </table>
  87. </div>
  88. <div class="column2">
  89.     <h3><?php echo $this->translate->_ ( 'Personal Information' ); ?></h3>
  90.     <table id="addFormTable3">
  91.         <tr class="odd">
  92.             <td><label for="prefix"><?=$this->form->prefix->getLabel ();?>:</label></td>
  93.             <td><?=$this->form->prefix;?></td>
  94.         </tr>
  95.         <tr class="even">
  96.             <td><label for="firstName"><?=$this->form->firstName->getLabel ();?>:</label></td>
  97.             <td><?=$this->form->firstName;?></td>
  98.         </tr>
  99.         <tr class="odd">
  100.             <td><label for="lastName"><?=$this->form->lastName->getLabel ();?>:</label></td>
  101.             <td><?=$this->form->lastName;?></td>
  102.         </tr>
  103.         <tr class="even">
  104.             <td><label for="suffix"><?=$this->form->suffix->getLabel ();?>:</label></td>
  105.             <td><?=$this->form->suffix;?></td>
  106.         </tr>
  107.         <tr class="odd">
  108.             <td><label for="dob"><?php echo $this->translate ( 'Date of Birth' ); ?></label></td>
  109.             <td><?=$this->form->dobMonth;?>&nbsp;/&nbsp;<?=$this->form->dobDay;?>&nbsp;/&nbsp;<?=$this->form->dobYear;?></td>
  110.         </tr>
  111.         <tr class="even">
  112.             <td><label for="gender"><?=$this->form->gender->getLabel ();?>:</label></td>
  113.             <td><?=$this->form->gender;?></td>
  114.         </tr>
  115.         <tr class="odd">
  116.             <td><label for="Dependants"><?=$this->form->dependants->getLabel ();?>:</label></td>
  117.             <td><?=$this->form->dependants;?><?php echo $this->translate ( 'Minors and Adults' );?></td>
  118.         </tr>
  119.     </table>
  120.    
  121.     <h3><?php echo $this->translate->_ ( 'Registration' );?></h3>
  122.     <table id="addFormTable4">
  123.         <tr class="odd"><td><?php echo $this->translate ('Current Residence (Patients Only)'); ?></td><td></td></tr>
  124.             <tr class="even">
  125.                 <td><label for="address"><?=$this->form->address->getLabel ();?>: </label></td>
  126.                 <td><?=$this->form->address;?></td>
  127.             </tr>
  128.             <tr class="odd">
  129.                 <td><label for="city"><?=$this->form->city->getLabel ();?>: </label></td>
  130.                 <td><?=$this->form->city;?></td>
  131.             </tr>
  132.             <tr class="even">
  133.                 <td><label for="state"><?=$this->form->state->getLabel ();?>: </label></td>
  134.                 <td><?=$this->form->state;?></td>
  135.             </tr>
  136.             <tr class="odd">
  137.                 <td><label for="zip"><?=$this->form->zip->getLabel ();?>: </label></td>
  138.                 <td><?=$this->form->zip;?></td>
  139.             </tr>
  140.             <tr class="even">
  141.                 <td><label for="primaryPhone1"><?php
  142.                 echo $this->translate ( 'Primary Phone' ); ?>:</label></td>
  143.                 <td><?=$this->form->primaryPhone1;?>&nbsp;-&nbsp;<?=$this->form->primaryPhone2;?>&nbsp;-&nbsp;<?=$this->form->primaryPhone3;?></td>
  144.             </tr>
  145.             <tr class="odd">
  146.                 <td><label for="secondaryPhone1"><?php echo $this->translate ( 'Secondary Phone' );?>: </label></td>
  147.                 <td><?=$this->form->secondaryPhone1;?>&nbsp;-&nbsp;<?=$this->form->secondaryPhone2;?>&nbsp;-&nbsp;<?=$this->form->secondaryPhone3;?></td>
  148.             </tr>
  149.             <tr class="even">
  150.                 <!-- added needs intergration to db replacing personal info tab in med history -->
  151.                 <td><label for="billingq"><?=$this->form->billingq->getLabel ();?>: </label></td>
  152.                 <td><?=$this->form->billingq;?></td>
  153.             </tr>
  154.     </table>
  155. </div>
  156. <div class="formControls"><input type="submit"
  157.     value="<?php
  158.     echo $this->translate ( 'Submit' );
  159.     ?>" /></div>
  160. </form>
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