100 lines
5.0 KiB
PHP
100 lines
5.0 KiB
PHP
<?php
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session_start();
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// Proteger la página
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if (!isset($_SESSION['user_id'])) {
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header('Location: login.php');
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exit;
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}
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$username = $_SESSION['username'] ?? 'Usuario';
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?>
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<!DOCTYPE html>
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<html lang="en">
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<head>
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<meta charset="UTF-8">
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<meta name="viewport" content="width=device-width, initial-scale=1.0">
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<title>CDT Health Care - Patient Transfer</title>
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<meta name="description" content="Built with CDT Health Care">
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<meta name="keywords" content="patient transfer, ambulance, hospital, emergency, medical, Built with CDT Health Care">
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<meta property="og:title" content="CDT Health Care - Patient Transfer">
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<meta property="og:description" content="Built with CDT Health Care">
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<meta property="og:image" content="">
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<meta name="twitter:card" content="summary_large_image">
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<meta name="twitter:image" content="">
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<link href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.0-alpha1/dist/css/bootstrap.min.css" rel="stylesheet">
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<link rel="stylesheet" href="assets/css/custom.css">
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</head>
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<body>
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<nav class="navbar navbar-expand-lg navbar-light bg-light shadow-sm">
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<div class="container">
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<a class="navbar-brand" href="index.php">CDT Health Care</a>
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<ul class="navbar-nav ms-auto">
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<li class="nav-item dropdown">
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<a class="nav-link dropdown-toggle" href="#" id="navbarDropdown" role="button" data-bs-toggle="dropdown" aria-expanded="false">
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<?= htmlspecialchars($username) ?>
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</a>
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<ul class="dropdown-menu" aria-labelledby="navbarDropdown">
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<?php if ($_SESSION['role'] === 'admin'): ?>
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<li><a class="dropdown-item" href="dashboard.php">Admin Dashboard</a></li>
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<li><hr class="dropdown-divider"></li>
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<?php endif; ?>
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<li><a class="dropdown-item" href="logout.php">Cerrar Sesión</a></li>
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</ul>
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</li>
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</ul>
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</div>
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</nav>
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<header class="bg-primary text-white text-center py-3">
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<h1>Patient Transfer Request</h1>
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</header>
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<main class="container mt-5">
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<div class="card shadow-sm">
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<div class="card-body">
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<h2 class="card-title text-center mb-4">New Patient</h2>
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<form id="patient-form" action="add_patient.php" method="POST">
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<div class="row">
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<div class="col-md-6 mb-3">
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<label for="name" class="form-label">Name</label>
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<input type="text" class="form-control" id="name" name="name" required>
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</div>
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<div class="col-md-6 mb-3">
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<label for="lastname" class="form-label">Last Name</label>
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<input type="text" class="form-control" id="lastname" name="lastname" required>
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</div>
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</div>
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<div class="row">
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<div class="col-md-6 mb-3">
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<label for="age" class="form-label">Age</label>
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<input type="number" class="form-control" id="age" name="age" required>
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</div>
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<div class="col-md-6 mb-3">
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<label for="insurance" class="form-label">Health Insurance</label>
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<input type="text" class="form-control" id="insurance" name="insurance" required>
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</div>
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</div>
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<div class="mb-3">
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<label for="symptoms" class="form-label">Symptoms</label>
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<textarea class="form-control" id="symptoms" name="symptoms" rows="3" required></textarea>
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</div>
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<div class="mb-3">
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<label for="specialty" class="form-label">Urgency Specialty</label>
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<input type="text" class="form-control" id="specialty" name="specialty" required>
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</div>
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<div class="mb-3">
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<label for="pre_arrival_instructions" class="form-label">Pre-arrival Instructions</label>
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<textarea class="form-control" id="pre_arrival_instructions" name="pre_arrival_instructions" rows="3" required></textarea>
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</div>
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<div class="d-grid">
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<button type="submit" class="btn btn-primary">Submit</button>
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</div>
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</form>
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<div id="success-message" class="alert alert-success mt-4 d-none" role="alert">
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Patient data submitted successfully!
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</div>
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</div>
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</div>
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</main>
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<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.3.0-alpha1/dist/js/bootstrap.bundle.min.js"></script>
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<script src="assets/js/main.js"></script>
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</body>
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</html>
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