{% extends 'base_patient.html' %}
{% load static %}

{% block content %}

<!-- Title -->
<h1 class="section-title" id="services">
	<span>Request for Lab Test</span>
</h1><!-- End Title -->

<div class="section section-custom billinfo pmd-content pmd-content-custom"> 
	<form id="validationForm" method="post">
		{% csrf_token %}
		<div class="pmd-card pmd-z-depth">
			<div class="pmd-card-body">
				<div class="group-fields clearfix row">
					<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
						<div class="form-group pmd-textfield pmd-textfield-floating-label">       
							<label>Type Of Test</label>
							<select name="testtype" class="select-simple form-control pmd-select2">
								<option></option>
								<option value="Metabolism Panel">Basic Metabolism</option>
								<option value="Common Blood Count">Common Blood Counts</option>
								<option value="MRI">MRI</option>
								<option value="X-Ray">X-Ray</option>
							</select>
						</div>
					</div>
							
					<div class="col-lg-4 col-md-4 col-sm-4 col-xs-12">
						<div class="form-group pmd-textfield">
							<label for="regular1" class="control-label">Select Date and Time</label>
							<input type="date" name="labdate" id="simple" class="form-control input-sm">
						</div>
					</div>
				</div>
			</div>		
			<div class="pmd-card-actions">
				<input type="Submit" class="btn btn-primary next">
			</div>
		</div> <!-- section content end -->  
	</form>
</div>
{% endblock %}    
