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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Patient Information Form</title>
<script src="https://cdn.tailwindcss.com"></script>
<script src="https://unpkg.com/feather-icons"></script>
<script src="https://cdn.jsdelivr.net/npm/feather-icons/dist/feather.min.js"></script>
<link href="https://fonts.googleapis.com/css2?family=Inter:wght@300;400;500;600;700&display=swap" rel="stylesheet">
<style>
.form-section {
transition: all 0.3s ease;
}
.form-section:hover {
box-shadow: 0 4px 6px -1px rgba(0, 0, 0, 0.1), 0 2px 4px -1px rgba(0, 0, 0, 0.06);
}
.dropdown-arrow {
transition: transform 0.2s ease;
}
.dropdown-toggle:focus + .dropdown-arrow {
transform: rotate(180deg);
}
input:focus, select:focus, textarea:focus {
outline: none;
box-shadow: 0 0 0 2px rgba(59, 130, 246, 0.5);
}
</style>
</head>
<body class="bg-gray-50 font-inter">
<div class="container mx-auto px-4 py-8 max-w-6xl">
<div class="bg-white rounded-lg shadow-md overflow-hidden mb-8">
<div class="bg-blue-600 px-6 py-4">
<h1 class="text-2xl font-bold text-white flex items-center">
<i data-feather="user" class="mr-2"></i>
Patient Information Form
</h1>
</div>
<form class="p-6 space-y-8">
<!-- Personal Information Section -->
<div class="form-section bg-white border border-gray-200 rounded-lg p-6">
<div class="flex items-center justify-between mb-4">
<h2 class="text-lg font-semibold text-gray-800">Personal Information</h2>
<i data-feather="chevron-down" class="text-gray-500 dropdown-arrow"></i>
</div>
<div class="grid grid-cols-1 md:grid-cols-2 lg:grid-cols-3 gap-6">
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Patient ID</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm focus:ring-blue-500 focus:border-blue-500">
<option value="">Select Patient ID</option>
<!-- Dropdown options would be populated here -->
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Last Name</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">First Name</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Middle Name</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Preferred Name</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Suffix</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Birthdate</label>
<input type="date" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Account Number</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Customer Type</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Type</option>
<option value="facility_master">Facility Master</option>
<option value="facility_resident">Facility Resident</option>
<option value="patient">Patient</option>
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Prior System Key</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Facility</label>
<div class="relative">
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="Search facility...">
<i data-feather="search" class="absolute right-3 top-2.5 text-gray-400"></i>
</div>
</div>
</div>
</div>
<!-- Billing Address Section -->
<div class="form-section bg-white border border-gray-200 rounded-lg p-6">
<div class="flex items-center justify-between mb-4">
<h2 class="text-lg font-semibold text-gray-800">Billing Address</h2>
<i data-feather="chevron-down" class="text-gray-500 dropdown-arrow"></i>
</div>
<div class="grid grid-cols-1 md:grid-cols-2 gap-6">
<div class="col-span-2">
<label class="block text-sm font-medium text-gray-700 mb-1">Address</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div class="col-span-2">
<label class="block text-sm font-medium text-gray-700 mb-1">Address 2</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">City</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">State</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">County</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Country</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Postal Code</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="_____-____">
</div>
</div>
</div>
<!-- Campaign Information Section -->
<div class="form-section bg-white border border-gray-200 rounded-lg p-6">
<div class="flex items-center justify-between mb-4">
<h2 class="text-lg font-semibold text-gray-800">Campaign Information</h2>
<i data-feather="chevron-down" class="text-gray-500 dropdown-arrow"></i>
</div>
<div class="grid grid-cols-1 md:grid-cols-2 lg:grid-cols-3 gap-6">
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Incont Campaign</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Status</option>
<option value="successful">Successful</option>
<option value="unsuccessful">Unsuccessful</option>
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Compress Campaign</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Status</option>
<option value="successful">Successful</option>
<option value="unsuccessful">Unsuccessful</option>
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Mailer - Incont Campaign</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Status</option>
<option value="successful">Successful</option>
<option value="unsuccessful">Unsuccessful</option>
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Clamp On Rail Campaign</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Status</option>
<option value="successful">Successful</option>
<option value="unsuccessful">Unsuccessful</option>
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">BP Machines Campaign</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Status</option>
<option value="successful">Successful</option>
<option value="unsuccessful">Unsuccessful</option>
</select>
</div>
</div>
</div>
<!-- Extended Information Section -->
<div class="form-section bg-white border border-gray-200 rounded-lg p-6">
<div class="flex items-center justify-between mb-4">
<h2 class="text-lg font-semibold text-gray-800">Extended Information</h2>
<i data-feather="chevron-down" class="text-gray-500 dropdown-arrow"></i>
</div>
<div class="grid grid-cols-1 md:grid-cols-2 lg:grid-cols-3 gap-6">
<div class="flex items-center space-x-2">
<input type="checkbox" id="holdAccount" class="h-4 w-4 text-blue-600 focus:ring-blue-500 border-gray-300 rounded">
<label for="holdAccount" class="text-sm font-medium text-gray-700">Hold Account</label>
</div>
<div class="flex items-center space-x-2">
<input type="checkbox" id="holdBilling" class="h-4 w-4 text-blue-600 focus:ring-blue-500 border-gray-300 rounded">
<label for="holdBilling" class="text-sm font-medium text-gray-700">Hold Billing Statements</label>
</div>
<div class="flex items-center space-x-2">
<input type="checkbox" id="hipaa" class="h-4 w-4 text-blue-600 focus:ring-blue-500 border-gray-300 rounded">
<label for="hipaa" class="text-sm font-medium text-gray-700">HIPAA Signature on file</label>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Discount Percent</label>
<div class="relative">
<input type="number" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="%">
<span class="absolute right-3 top-2.5 text-gray-500">%</span>
</div>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Tax Zone</label>
<div class="relative">
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="Search tax zone...">
<i data-feather="search" class="absolute right-3 top-2.5 text-gray-400"></i>
</div>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Branch Office</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Branch</option>
<option value="nhms">New Hampshire Medical Supply</option>
<option value="nhms_bra">NHMS BRA</option>
<option value="nhms_bsc">NHMS BSC</option>
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Account Group</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="1-9 A-Z">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">PT Security Group</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select PCA</option>
<!-- PCA options would be populated here -->
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">User 1</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Patient Hub Email Address</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="not_invited">Not Invited</option>
<!-- Other options would be here -->
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Place of Service</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">Select Place</option>
<option value="12">12 Home</option>
<option value="17">17 Walkin Retail clinic</option>
<!-- Other options would be here -->
</select>
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Date of Admission</label>
<input type="date" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Date of Discharge</label>
<input type="date" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
</div>
</div>
<!-- Delivery Addresses Section -->
<div class="form-section bg-white border border-gray-200 rounded-lg p-6">
<div class="flex items-center justify-between mb-4">
<h2 class="text-lg font-semibold text-gray-800">Delivery Addresses</h2>
<i data-feather="chevron-down" class="text-gray-500 dropdown-arrow"></i>
</div>
<div class="flex items-center mb-4">
<input type="checkbox" id="activeOnly" class="h-4 w-4 text-blue-600 focus:ring-blue-500 border-gray-300 rounded">
<label for="activeOnly" class="ml-2 text-sm font-medium text-gray-700">Active Addresses Only</label>
</div>
<div class="grid grid-cols-1 md:grid-cols-2 gap-6">
<div class="col-span-2">
<label class="block text-sm font-medium text-gray-700 mb-1">Address</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">City</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">State</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">County</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Country</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Postal Code</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="_____-____">
</div>
<div class="col-span-2">
<label class="block text-sm font-medium text-gray-700 mb-1">Description</label>
<input type="text" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Phone</label>
<input type="tel" class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm" placeholder="(___) ___-____">
</div>
<div>
<label class="block text-sm font-medium text-gray-700 mb-1">Zone</label>
<select class="w-full px-3 py-2 border border-gray-300 rounded-md shadow-sm">
<option value="">None</option>
<!-- Zone options would be populated here -->
</select>
</div>
</div>
</div>
<!-- Form Actions -->
<div class="flex justify-end space-x-4 pt-6">
<button type="button" class="px-4 py-2 border border-gray-300 rounded-md shadow-sm text-sm font-medium text-gray-700 bg-white hover:bg-gray-50 focus:outline-none focus:ring-2 focus:ring-offset-2 focus:ring-blue-500">
Cancel
</button>
<button type="submit" class="px-4 py-2 border border-transparent rounded-md shadow-sm text-sm font-medium text-white bg-blue-600 hover:bg-blue-700 focus:outline-none focus:ring-2 focus:ring-offset-2 focus:ring-blue-500">
Save Patient
</button>
</div>
</form>
</div>
</div>
<script>
feather.replace();
// Add interactivity to dropdown sections
document.querySelectorAll('.form-section').forEach(section => {
const header = section.querySelector('.flex.items-center.justify-between');
const content = section.querySelectorAll('div:not(.flex.items-center.justify-between)');
const arrow = section.querySelector('.dropdown-arrow');
header.addEventListener('click', () => {
content.forEach(el => {
el.classList.toggle('hidden');
});
arrow.classList.toggle('rotate-180');
});
});
</script>
</body>
</html>
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