{% extends 'template.html' %}
{% block title %}Pasien Baru{% endblock %}
{% block subcontent %}
		{% if session.flash.error != "" %}
			{{ session.flash.error | safe }}
		{% endif %}
	
		<h2>Data Pasien > Tambah Pasien</h2>
		<form method="post">
			<table class="data" cellpadding="0" cellspacing="0" border="0">
				<tr>
					<td>No. RekMed</td>
					<td><input type="text" name="no_rekmed" value="{{ data.no_rekmed }}"/></td>
				</tr>
				<tr>
					<td>No. Identitas</td>
					<td><input type="text" name="no_nik" value="{{ data.no_nik }}"/></td>
				</tr>
				<tr>
					<td>Nama Lengkap</td>
					<td><input type="text" name="nama" value="{{ data.nama }}"/></td>
				</tr>
				<tr>
					<td>Nama Keluarga</td>
					<td><input type="text" name="namakel" value="{{ data.namakel }}"/></td>
				</tr>
				<tr>
					<td>Tgl Lahir</td>
					<td><input type="text" name="tgl_lahir" value="{{ data.tgl_lahir }}"/>dd-mm-yyyy</td>
				</tr>
				<tr>
					<td>Jns Kelamin</td>
					<td>
						<select name="sex">
							<option value="L" {% if data.sex == 'L' %}selected="true"{% endif %}>Laki-Laki</option>
							<option value="P" {% if data.sex == 'P' %}selected="true"{% endif %}>Perempuan</option>
						</select>
					</td>
				</tr>
				<tr>
					<td>Alamat</td>
					<td><textarea name="alamat" style="width:250px;" >{{ data.alamat }}</textarea></td>
				</tr>
				<tr>
					<td>Telepon</td>
					<td><input type="text" name="tlp" value="{{ data.tlp }}"/></td>
				</tr>
				<tr>
					<td>Golongan</td>
					<td>
						<select name="golongan">
							<option value="1" {% if data.golongan == '1' %}selected="true"{% endif %}>Dhuafa</option>
							<option value="2" {% if data.golongan == '2' %}selected="true"{% endif %}>Umum</option>
							<option value="3" {% if data.golongan == '3' %}selected="true"{% endif %}>Khusus</option>
						</select>
					</td>
				</tr>
			</table>
			<br/><input type="submit" class="med_btn" value="Simpan" /> <a class="med_btn" href="{% nav registrasi_pasien %}">Batal</a>
		</form>
{% endblock %}
