<?php print_lang('add_new_pat_direct_billing_list'); ?>
<?php $this :: display_page_errors(); ?>
" method="post" >
<?php
for( $row = 1; $row <= 1; $row++ ){
?>
<?php
}
?>
| <?php print_lang('pats_id'); ?> | <?php print_lang('docid'); ?> | <?php print_lang('lab_no'); ?> | <?php print_lang('bill_no'); ?> | <?php print_lang('item_testname_id'); ?> | <?php print_lang('unit_price'); ?> | <?php print_lang('quantity'); ?> | <?php print_lang('total_price'); ?> | |
|---|---|---|---|---|---|---|---|---|
|
<?php print_lang('select_a_value_'); ?>
<?php
$pats_id_options = $comp_model -> pat_direct_billing_list_pats_id_option_list();
if(!empty($pats_id_options)){
foreach($pats_id_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('pats_id',$value, $comp_model->pat_direct_billing_list_pats_id_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
|
<?php print_lang('select_a_value_'); ?>
<?php
$docid_options = $comp_model -> pat_direct_billing_list_docid_option_list();
if(!empty($docid_options)){
foreach($docid_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('docid',$value, $comp_model->pat_direct_billing_list_docid_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
|
<?php print_lang('select_a_value_'); ?>
<?php
$lab_no_options = $comp_model -> pat_direct_billing_list_lab_no_option_list();
if(!empty($lab_no_options)){
foreach($lab_no_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('lab_no',$value, $comp_model->pat_direct_billing_list_lab_no_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
|
<?php print_lang('select_a_value_'); ?>
<?php
$bill_no_options = $comp_model -> pat_direct_billing_list_bill_no_option_list();
if(!empty($bill_no_options)){
foreach($bill_no_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('bill_no',$value, $comp_model->pat_direct_billing_list_bill_no_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
|
<?php print_lang('select_a_value_'); ?>
<?php
$item_testname_id_options = $comp_model -> pat_direct_billing_list_item_testname_id_option_list();
if(!empty($item_testname_id_options)){
foreach($item_testname_id_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('item_testname_id',$value, "");
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
|
" type="text" placeholder="<?php print_lang('enter_unit_price'); ?>" required="" name="row<?php echo $row ?>[unit_price]" class="form-control " />
|
" type="text" placeholder="<?php print_lang('enter_quantity'); ?>" required="" name="row<?php echo $row ?>[quantity]" class="form-control " />
|
" type="text" placeholder="<?php print_lang('enter_total_price'); ?>" required="" name="row<?php echo $row ?>[total_price]" class="form-control " />
|
× |
| <?php $template_id = "table-row-" . random_str(); ?> |
<?php print_lang('submit'); ?>
<?php $row = 1; ?>
<?php print_lang('select_a_value_'); ?>
<?php
$pats_id_options = $comp_model -> pat_direct_billing_list_pats_id_option_list();
if(!empty($pats_id_options)){
foreach($pats_id_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('pats_id',$value, $comp_model->pat_direct_billing_list_pats_id_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
<?php print_lang('select_a_value_'); ?>
<?php
$docid_options = $comp_model -> pat_direct_billing_list_docid_option_list();
if(!empty($docid_options)){
foreach($docid_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('docid',$value, $comp_model->pat_direct_billing_list_docid_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
<?php print_lang('select_a_value_'); ?>
<?php
$lab_no_options = $comp_model -> pat_direct_billing_list_lab_no_option_list();
if(!empty($lab_no_options)){
foreach($lab_no_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('lab_no',$value, $comp_model->pat_direct_billing_list_lab_no_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
<?php print_lang('select_a_value_'); ?>
<?php
$bill_no_options = $comp_model -> pat_direct_billing_list_bill_no_option_list();
if(!empty($bill_no_options)){
foreach($bill_no_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('bill_no',$value, $comp_model->pat_direct_billing_list_bill_no_default_value());
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
<?php print_lang('select_a_value_'); ?>
<?php
$item_testname_id_options = $comp_model -> pat_direct_billing_list_item_testname_id_option_list();
if(!empty($item_testname_id_options)){
foreach($item_testname_id_options as $option){
$value = (!empty($option['value']) ? $option['value'] : null);
$label = (!empty($option['label']) ? $option['label'] : $value);
$selected = $this->set_field_selected('item_testname_id',$value, "");
?>
value="<?php echo $value; ?>">
<?php echo $label; ?>
<?php
}
}
?>
" type="text" placeholder="<?php print_lang('enter_unit_price'); ?>" required="" name="row<?php echo $row ?>[unit_price]" class="form-control " />
" type="text" placeholder="<?php print_lang('enter_quantity'); ?>" required="" name="row<?php echo $row ?>[quantity]" class="form-control " />
" type="text" placeholder="<?php print_lang('enter_total_price'); ?>" required="" name="row<?php echo $row ?>[total_price]" class="form-control " />
×