{% 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="{{ rm }}"/></td>
				</tr>
				<tr>
					<td>Kelompok</td>
					<td>
						<select name="kelompok">
							<option value="-">-</option>
							<option value="baksos">Baksos</option>
						</select>
					</td>
				</tr>
				<tr>
					<td>No. Identitas</td>
					<td><input type="text" name="no_nik" value=""/></td>
				</tr>
				<tr>
					<td>Nama Lengkap</td>
					<td><input type="text" name="nama" value=""/></td>
				</tr>
				<tr>
					<td>Nama Keluarga</td>
					<td><input type="text" name="namakel" value=""/></td>
				</tr>
				<tr>
					<td>Tgl Lahir</td>
					<td><input type="text" name="tgl_lahir" value=""/>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;" ></textarea></td>
				</tr>
				<tr>
					<td>Telepon</td>
					<td><input type="text" name="tlp" value=""/></td>
				</tr>
				<tr>
					<td>Golongan</td>
					<td>
						<select name="id_golongan">
							{% for g in golongan %}
							<option value="{{ g.id }}">{{ g.nama }}</option>
							{% endfor %}
						</select>
					</td>
				</tr>
			</table>
			<br/><input type="submit" class="btn btn-success" value="Simpan" /> <a class="btn btn-danger" href="{% nav registrasi_administrasi_pasien %}">Batal</a>
		</form>
{% endblock %}
{% block script %}
<script type="text/javascript">
	var totalT = 0;
	var totalO = 0;
	$(document).ready(function() {
		menuSelected("mAdministrasi","smPasien");
	});
</script>
{% endblock %}