
<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-user"></i>Complaints
                        </div>
                    </div>
                    <div class="portlet-body">

                        <!--Begin Semen-->

                        <div class="row">


                            <div class="portlet-title tbox">
                            </div>

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

                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=complaint_update" 
                                  method="post" class="clinick"  style="direction: rtl;">
                                <div class="form-body">
                                    <div class="row">

                                        <div class="col-md-6">
                                            <div class="form-group">
                                                <label class="control-label col-md-3 ls2">اسم المريض </label>
                                                <select class="form-control select2me" data-placeholder="Select..." 
                                                        name="patientid"  id="patientService" required="required">
                                                    <option></option>
                                                    {foreach $patients as $row}
                                                    <option value="{$row.id}" {if $complaint->patientid  == $row.id } selected {/if}>{$row.wifename} - {$row.husdandname}</option>
                                                    {/foreach}
                                                </select>
                                            </div>
                                        </div>

                                        <div class="col-md-3">
                                            <div class="form-group form-md-line-input form-md-floating-label has-info">
                                                <input type="text" name="statusNo" id="statusNo" 
                                                       class="form-control searchPat txtc positiveNo">
                                                <label for="form_control_1">رقم المريض </label>
                                            </div>
                                        </div>

                                        <div class="col-md-3">
                                            <div class="form-group form-md-line-input form-md-floating-label has-info">
                                                <input type="text" name="phone" id="phone" 
                                                       class="form-control searchPatPhone txtc  digitsOnly">
                                                <label for="form_control_1">التليفون</label>
                                            </div>
                                        </div>

                                    </div>

                                    <div class="row">

                                        <div class="col-md-6">
                                            <div class="form-group form-md-line-input form-md-floating-label has-info">
                                                <textarea class="form-control has-info " rows="5"  name="reply" required>
                                                     {$complaint->reply}
                                                </textarea>
                                                <label for="form_control_1">الرد</label>
                                            </div>
                                        </div>

                                        <div class="col-md-6">
                                            <div class="form-group form-md-line-input form-md-floating-label has-info">
                                                <textarea class="form-control has-info" rows="5" name="complaiv" required>
                                                     {$complaint->complaiv}
                                                </textarea>
                                                <label for="form_control_1">الشكوى</label>
                                            </div>
                                        </div>

                                        <input type="hidden" id="complaint_id"   name="complaint_id"    value="{$complaint->id}"/>
                                    </div>
                                </div>

                                <div class="form-actions">
                                    <div class="row">
                                        <div class="col-md-offset-2 col-md-10">
                                            <button type="submit" class="btn blue">إضافة </button>
                                            <a class="btn default" href="{$hosturl}/controllers/{$controllname}.php?ac=complaint_show">إلغاء</a>
                                        </div>
                                    </div>
                                </div>
                            </form>
                        </div>
                    </div>
                </div>
            </div>
        </div>
    </div>
</div>

<input type="hidden" id="controllName" value="customer_service"/>


