72 lines
2.7 KiB
Twig
72 lines
2.7 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">Add Referral</h4>
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<p class="mb-0">{{ case.caseName }}</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='input-group input-group-outline mb-3'>
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<label for='referral_form_referralId' class='form-label'>Referral ID</label>
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<input type='text' name='{{ field_name(form.referralId) }}' id='referral_form_referralId' 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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<select name='{{ field_name(form.serviceCode) }}' id='referral_form_serviceCode' class='form-control'>
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<option value=''>-- Select Service Code --</option>
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{% for sc in enum('App\\Enums\\ReferralServiceType').cases() %}
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<option value='{{ sc.value }}'>{{ sc.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='referral_form_hours' class='form-label'>Hours</label>
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<input type='number' name='{{ field_name(form.hours) }}' id='referral_form_hours' 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='referral_form_endDate' class='form-label'></label>
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<input type='date' name='{{ field_name(form.endDate) }}' id='referral_form_endDate' 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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<select name='{{ field_name(form.dischargeReason) }}' id='referral_form_dischargeReason' class='form-control'>
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<option value=''>-- Select Discharge Reason --</option>
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{% for dr in enum('App\\Enums\\DischargeReason').cases() %}
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<option value='{{ dr.value }}'>{{ dr.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='referral_form_dischargeDate' class='form-label'></label>
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<input type='date' name='{{ field_name(form.dischargeDate) }}' id='referral_form_dischargeDate' class='form-control'/>
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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 Referral</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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