
<div class="page-content-wrapper">
    <div class="page-content">
        <div class="row">
            <div class="col-md-12">
                <!-- BEGIN EXAMPLE TABLE PORTLET-->
                <div class="portlet box blue">
                    <div class="portlet-title">
                        <div class="caption">
                            <i class="fa fa-cogs"></i>Patient Decleration
                        </div>
                        <div class="actions">

                            {if $patientId}

                            <a href="{$hosturl}/controllers/{$controllname}.php?ac=show&patientid={$patientId}" class="btn btn-default btn-sm">
                                <i class="fa fa-"></i> Show</a>
                            {else}
                            <a href="{$hosturl}/controllers/{$controllname}.php?ac=show" class="btn btn-default btn-sm">
                                <i class="fa fa-"></i> Show</a>
                            {/if}

                        </div>
                    </div>
                    <div class="portlet-body">
                        <input type="hidden" id="patientdecleration" value="1"/>
                        <input type="hidden" id="patientId" value="{$patientid}"/>
                        <input type="hidden" id="controllName" value="patientdecleration"/>
                        <!--Begin Semen-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-blue-haze col-md-6">
                                    <span class="caption-subject bold ">Add Patient Decleration</span>
                                </div>

                            </div>

                            <div class="clearfix"></div>

                            {if $patientId}
                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=addit&patientid={$patientId}" method="post" class="clinick" id="p_decleration_form" enctype="multipart/form-data">
                                {/if}
                                <div class="form-body">


                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label class="col-md-4 control-label" for="form_control_1">Decleration Name</label>
                                            <div class="col-md-8">
                                                <select class="form-control select2me updateElement" data-placeholder="Select..." name="decleration_name" id="decleration">
                                                    <option></option>
                                                    {foreach $decleration as $sname}
                                                    <option value="{$sname.id}">{$sname.title}</option>
                                                    {/foreach}
                                                </select>
                                                <div class="form-control-focus">
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <!--                                <div class="fileinput-preview thumbnail fleft" data-trigger="fileinput" style="width: 40px; height: 37px;">
                                                                    <img src="{$hosturl}/../upload/decleration_files/{$programesetting.background}" id="backgroundImage"  />
                                                                </div>-->
                                <div class="fleft">
                                    <span class="btn default btn-file"> <span class="fileinput-new"> Upload Image</span>
                                        <input type="file" name="bgfile" id="background" >
                                    </span>
                                </div>
                                <div class="form-actions">
                                    <div class="row">
                                        <div class="col-md-offset-2 col-md-10">
                                            <div class="row">
                                                <div class="col-md-offset-2 col-md-10 hidPrint">
                                                    <button type="submit" id="doneBtn" class="btn blue" >Save</button>
                                                    <button type="button" class="btn showPrintDec"  style=" margin: 20px auto; float: none; ">Print</button>
                                                    {if $patientId}
                                                    <a class="btn default" href="{$hosturl}/controllers/{$controllname}.php?ac=show&patientid={$patientId}">Cancel</a>
                                                    {/if}
                                                </div>
                                                <br>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </form>

                        </div>
                    </div>
                </div>
            </div>





        </div>
    </div>
</div>
<div id="vvv"></div>


