

<div class="page-content-wrapper">
    <div class="page-content">
        <div class="row">
            <input type="hidden" id="patientdecleration" value="1"/>
            <input type="hidden" id="patientId" value="{$patientid}"/>
            <input type="hidden" id="controllName" value="patientdecleration"/>
            <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>Patient Decleration
                        </div>
                    </div>
                    <div class="portlet-body">

                        <!--Begin Semen-->

                        <div class="row">


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

                            </div>

                            <div class="clearfix"></div>
                            {if $patientId}
                            <form action="{$hosturl}/controllers/{$controllname}.php?ac=updateit&patientid={$patientId}" method="post" class="form-horizontal" 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}"  {if $sname.id == $editElement.decleration_id}selected{/if} >{$sname.title}</option>
                                                    {/foreach}
                                                </select>
                                                <div class="form-control-focus">
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <input type="hidden" name="edit_file" value="{$editElement.uploadfile}" >
                                <input type="hidden" name="edit_declar" value="{$editElement.id}" >




                                <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>

                                {if  $editElement.uploadfile && $editElement.uploadfile !='' && $editElement.uploadfile !=  'no image' }
                                <a class="btn blue" download="{$patientdata.wifename} - {$decl->title} - {$editElement.date|date_format}" href="{$hosturl}/../upload/decleration_files/{$editElement.uploadfile}">Download</a>
                                {/if}


                                <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>

