154 lines
6.7 KiB
Twig
154 lines
6.7 KiB
Twig
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{% extends 'base.html.twig' %}
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{% block body %}
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{{ block('nav', 'internal/libs/nav.html.twig') }}
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<main class="main-content position-relative max-height-vh-100 h-100 border-radius-lg ">
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{{ block('topnav', 'internal/libs/top-nav.html.twig') }}
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<section>
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<div class="card card-plain">
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<div class="card-header">
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<h4 class="font-weight-bolder">Case Info</h4>
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<p class="mb-0"></p>
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</div>
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<div class="card-body">
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<div class="container">
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{{ form_errors(form) }}
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{{ form_start(form) }}
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<div class="row">
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<div class='col'>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_caseNumber' class='form-label'>Case #</label>
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<input type='text' name='{{ field_name(form.caseNumber) }}' id='case_form_caseNumber' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_dcsCaseId' class='form-label'>DCS Case ID</label>
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<input type='text' name='{{ field_name(form.dcsCaseId) }}' id='case_form_dcsCaseId' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3 is-filled'>
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<label for='case_form_admitDate' class='form-label'>Admit Date</label>
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<input type='date' name='{{ field_name(form.admitDate) }}' id='case_form_admitDate' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3 is-filled'>
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<label for='case_form_closeDate' class='form-label'>Close Date</label>
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<input type='date' name='{{ field_name(form.closeDate) }}' id='case_form_closeDate' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_caseEmail' class='form-label'>Case Email</label>
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<input type='text' name='{{ field_name(form.caseEmail) }}' id='case_form_caseEmail' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_referralType' class='form-label'>Referral Type</label>
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<input type='text' name='{{ field_name(form.referralType) }}' id='case_form_referralType' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3 is-filled'>
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<label for='case_form_level' class='form-label'>Level</label>
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<select name='{{ field_name(form.level) }}' id='case_form_level' class='form-control'>
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<option value=''></option>
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{% for l in enum('App\\Enums\\CaseLevel').cases() %}
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<option value='{{ l.value }}'>{{ l.name }}</option>
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{% endfor %}
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</select>
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</div>
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<div class='input-group input-group-outline mb-3 is-filled'>
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<label for='case_form_referralSource' class='form-label'>Referral Source</label>
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<select name='{{ field_name(form.referralSource) }}' id='case_form_referralSource' class='form-control'>
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<option value=''></option>
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{% for src in sources %}
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<option value='{{ src.id }}'>{{ src.name}}</option>
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{% endfor %}
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</select>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_referralSources2' class='form-label'>2nd Referral Source</label>
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<select name='{{ field_name(form.referralSource2) }}' id='case_form_referralSources2' class='form-control'>
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<option value=''></option>
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{% for src in sources %}
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<option value='{{ src.id }}'>{{ src.name }}</option>
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{% endfor %}
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</select>
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</div>
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</div>
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<div class='col'>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_firstName' class='form-label'>First Name</label>
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<input type='text' name='{{ field_name(form.firstName) }}' id='case_form_firstName' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_lastName' class='form-label'>Last Name</label>
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<input type='text' name='{{ field_name(form.lastName) }}' id='case_form_lastName' class='form-control' required='required'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_address' class='form-label'>Address</label>
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<input type='text' name='{{ field_name(form.address) }}' id='case_form_address' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_address2' class='form-label'>Address 2</label>
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<input type='text' name='{{ field_name(form.address2) }}' id='case_form_address2' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_city' class='form-label'>City</label>
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<input type='text' name='{{ field_name(form.city) }}' id='case_form_city' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_state' class='form-label'>State</label>
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<input type='text' name='{{ field_name(form.state) }}' id='case_form_state' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_zip' class='form-label'>Zip</label>
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<input type='text' name='{{ field_name(form.zip) }}' id='case_form_zip' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3 is-filled'>
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<label for='case_form_county' class='form-label'>County</label>
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<select name='{{ field_name(form.county) }}' id='case_form_county' class='form-control'>
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<option value=''></option>
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{% for c in enum('App\\Enums\\County').cases() %}
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<option value='{{ c.value }}'>{{ c.name }}</option>
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{% endfor %}
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</select>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_insurance' class='form-label'>Insurance</label>
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<input type='text' name='{{ field_name(form.insurance) }}' id='case_form_insurance' class='form-control'/>
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</div>
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<div class='input-group input-group-outline mb-3'>
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<label for='case_form_medicaid' class='form-label'>Medicaid</label>
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<input type='text' name='{{ field_name(form.medicaid) }}' id='case_form_medicaid' class='form-control'/>
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</div>
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</div>
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</div>
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<div class='row'>
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<div class="text-center">
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<button type="submit" class="btn btn-lg bg-gradient-dark btn-lg w-100 mt-4 mb-0">Save Case</button>
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</div>
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</div>
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{{ form_end(form) }}
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</div>
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</div>
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</div>
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</section>
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</main>
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{% endblock %}
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