97 lines
4.0 KiB
HTML
97 lines
4.0 KiB
HTML
{% extends "other_base.html" %}
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{% block title%}Submit|COVID-19 Detector{% endblock %}
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{% block content %}
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<div class="page-wrapper">
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<section class="page-header">
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</section><!-- /.page-header -->
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<div class="container">
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<h3>预约挂号申请</h3>
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<div class="appointment-info">
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<div class="appointment-row">
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<span class="appointment-row-label">就诊医院</span>
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<span class="appointment-row-value">{{ doctor.location }}</span>
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</div>
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<div class="appointment-row">
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<span class="appointment-row-label">就诊科室</span>
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<span class="appointment-row-value">感染科</span>
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</div>
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<div class="appointment-row">
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<span class="appointment-row-label">就诊医生</span>
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<span class="appointment-row-value">{{ doctor.name }}</span>
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</div>
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<div class="appointment-row">
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<span class="appointment-row-label">就诊时间</span>
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<span class="appointment-row-value" style="color: red;">{{ dateday.date }} {%if
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time=="1"%}上午{%else%}下午{%endif%}</span>
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</div>
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</div>
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<form method="POST">
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{{ form.hidden_tag() }}
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<div class="form-group row">
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<label for="name" class="col-sm-2 col-form-label">就诊人姓名</label>
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<div class="col-sm-6">
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{{ form.name(class="form-control", placeholder="请输入就诊人姓名", value=current_user.name or "") }}
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{% for error in form.name.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<div class="form-group row">
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<label for="id_number" class="col-sm-2 col-form-label">证件号</label>
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<div class="col-sm-6">
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{{ form.id_number(class="form-control", placeholder="请输入证件号",value=current_user.id_number or "") }}
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{% for error in form.id_number.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<div class="form-group row">
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<label for="phone" class="col-sm-2 col-form-label">手机号</label>
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<div class="col-sm-6">
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{{ form.phone(class="form-control", placeholder="请输入手机号",value=current_user.phone or "") }}
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{% for error in form.phone.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<div class="form-group row">
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<label for="email" class="col-sm-2 col-form-label">邮箱</label>
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<div class="col-sm-6">
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{{ form.email(class="form-control", placeholder="请输入邮箱",value=current_user.email or "") }}
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{% for error in form.email.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<div class="form-group row">
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<label for="gender" class="col-sm-2 col-form-label">性别</label>
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<div class="col-sm-6">
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{{ form.gender(class="form-control") }}
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{% for error in form.gender.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<div class="form-group row">
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<label for="age" class="col-sm-2 col-form-label">年龄</label>
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<div class="col-sm-6">
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{{ form.age(class="form-control", placeholder="请输入年龄",value=current_user.age or "") }}
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{% for error in form.age.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<div class="form-group row">
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<label for="location" class="col-sm-2 col-form-label">家庭地址</label>
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<div class="col-sm-6">
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{{ form.location(class="form-control", placeholder="请输入家庭地址",value=current_user.location or "") }}
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{% for error in form.location.errors %}
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<span class="text-danger">{{ error }}</span>
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{% endfor %}
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</div>
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</div>
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<button type="submit" class="btn btn-primary col-sm-8">提交</button>
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</form>
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</div>
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</div>
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{% endblock %} |