67 lines
2.6 KiB
Plaintext
67 lines
2.6 KiB
Plaintext
<!DOCTYPE html>
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<html lang="<%= lang %>">
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<head>
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<meta charset="UTF-8">
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<title><%= t.patientCreate.title %></title>
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<link rel="stylesheet" href="/css/bootstrap.min.css">
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</head>
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<body class="bg-light">
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<div class="container mt-5">
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<%- include("partials/flash") %>
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<div class="card shadow mx-auto" style="max-width: 600px;">
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<div class="card-body">
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<h3 class="mb-3"><%= t.patientCreate.title %></h3>
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<% if (error) { %>
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<div class="alert alert-danger"><%= error %></div>
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<% } %>
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<form method="POST" action="/patients/create">
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<input class="form-control mb-2" name="firstname"
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placeholder="<%= t.patientCreate.firstname %>" required>
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<input class="form-control mb-2" name="lastname"
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placeholder="<%= t.patientCreate.lastname %>" required>
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<input class="form-control mb-2" name="dni"
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placeholder="<%= t.patientCreate.dni %>" required>
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<select class="form-select mb-2" name="gender">
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<option value=""><%= t.global.gender %></option>
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<option value="m">Männlich</option>
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<option value="w">Weiblich</option>
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<option value="d">Divers</option>
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</select>
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<input class="form-control mb-2" type="date" name="birthdate" required>
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<input class="form-control mb-2" name="email"
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placeholder="<%= t.patientCreate.email %>">
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<input class="form-control mb-2" name="phone"
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placeholder="<%= t.patientCreate.phone %>">
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<input class="form-control mb-2" name="street"
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placeholder="<%= t.patientCreate.street %>">
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<input class="form-control mb-2" name="house_number"
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placeholder="<%= t.patientCreate.housenumber %>">
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<input class="form-control mb-2" name="postal_code"
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placeholder="<%= t.patientCreate.zip %>">
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<input class="form-control mb-2" name="city"
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placeholder="<%= t.patientCreate.city %>">
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<input class="form-control mb-2" name="country"
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placeholder="<%= t.patientCreate.country %>" value="Deutschland">
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<textarea class="form-control mb-3" name="notes"
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placeholder="<%= t.patientCreate.notes %>"></textarea>
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<button class="btn btn-primary w-100">
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<%= t.global.save %>
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</button>
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</form>
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</div>
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</div>
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</div>
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</body>
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</html>
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