{% extends 'base_patient.html' %}

{% block title %}Patient Sign Up{% endblock %}

{% block content %}
		<div class="section section-custom billinfo"> 
			<!--section-title -->
			<h2>Please provide the values for the patient with :</h2><!--  section-title end -->
			<!-- section content start-->
			<div class="pmd-card pmd-z-depth">
				<div class="pmd-card-body">	
					<form class="form-horizontal" role="form" method="POST" action="patient/patientSignup">
					{% csrf_token %}
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">First Name</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="fname" value="{{ patient_id }}" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Surname</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="lname" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Gender</label>
							<div class="col-sm-10">
								<select name="gender" class="form-control" id="exampleInputAmount">
    							<option value="Male">Male</option>
    							<option value="Female">Female</option>
    							<option value="Other">Other</option>
							</select>
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Date of Birth</label>
							<div class="col-sm-10">
								<input type="date" class="form-control input-sm" name="dob">
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Country</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="country" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Street Address</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="street" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">City</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="city" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">State</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="state" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">PIN Code</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="pinCode" type="text" >
							</div>
						</div>
						<div class="form-group pmd-textfield">
							<label for="inputEmail3" class="col-sm-2 control-label">Profile ID</label>
							<div class="col-sm-10">
								<input class="form-control input-sm" name="profile_id" value="{{ profile_id }}" type="text" readonly >
							</div>
						</div>
						<div class="pmd-card-footer card-footer-no-border card-footer-p16 text-center">
							<input type="Submit" class="btn pmd-ripple-effect btn-primary btn-block">
			  			</div>
					</form>
				</div>
			</div> <!-- section content end -->  
		</div>
{% endblock %}
