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| <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> | |