Produits Entr'ouvert » Calebasse

{% load widget_tweaks %}

<form id="contactform" action="{{ request.get_full_path }}" enctype="multipart/form-data" method="post">

  {% csrf_token %}

  <table>

    <tbody>

      <tr>

        <td>

          {{ form.first_name.label_tag }} :<br>

          {{ form.first_name.errors }}

          {{ form.first_name }}

        </td>

        <td>

          {{ form.last_name.label_tag }} :<br>

          {{ form.last_name.errors }}

          {{ form.last_name }}

        </td>

        <td>

          {{ form.gender.label_tag }} :<br>

          {{ form.gender }}

          {{ form.gender.errors }}

        </td>

      </tr>

      <tr>

        <td>

          {{ form.birthdate.label_tag }} :<br>

          {{ form.birthdate.errors }}

          {{ form.birthdate }}

        </td>

         <td>

          {{ form.birthplace.label_tag }} :<br>

          {{ form.birthplace.errors }}

          {{ form.birthplace }}

        </td>

        <td>

          {{ form.twinning_rank.label_tag }} :<br>

          {{ form.twinning_rank.errors }}

          {{ form.twinning_rank }}

        </td>

      </tr>

  </table>

  <table>

      <tr>

         <td>

          {{ form.parente.label_tag }} :<br>

          {{ form.parente.errors }}

          {{ form.parente }}

        </td>

        <td>

          {{ form.job.label_tag }} :<br>

          {{ form.job.errors }}

          {{ form.job }}

        </td>

      </tr>

      <tr>

        <td>

          Téléphone personnel :<br>

          {{ form.mobile.errors }}

          {{ form.mobile }}

        </td>

        <td>

          Téléphone professionnel :<br>

          {{ form.phone.errors }}

          {{ form.phone }}

        </td>

      </tr>

      <tr>

        <td>

          {{ form.email.label_tag }} :<br>

          {{ form.email.errors }}

          {{ form.email }}

        </td>

      </tr>

  </table>

  <table>

      <tr>

        <td id="social-security-id">

          {{ form.social_security_id.label_tag }} :<br>

          {{ form.social_security_id.errors }}

          {{ form.social_security_id }}

          <p id="nir-key">Clé : <span>-</span></p>

        </td>

      </tr>

      <tr>

        <td>

          {{ form.begin_rights.label_tag }} :<br>

          {{ form.begin_rights.errors }}

          {{ form.begin_rights }}

        </td>

        <td>

          {{ form.end_rights.label_tag }} :<br>

          {{ form.end_rights.errors }}

          {{ form.end_rights }}

        </td>

      </tr>

      <tr>

        <td>

          {{ form.health_org.label_tag }} :<br>

          {{ form.health_org.errors }}

          {{ form.health_org }}

        </td>

        <td>

          {{ form.other_health_center.label_tag }} :<br>

          {{ form.other_health_center.errors }}

          {{ form.other_health_center }}

        </td>

      </tr>

      <tr>

        <td>

          {{ form.type_of_contract.label_tag }} :<br>

          {{ form.type_of_contract.errors }}

          {{ form.type_of_contract }}

        </td>

        <td>

          {{ form.thirdparty_payer.label_tag }} :<br>

          {{ form.thirdparty_payer.errors }}

          {{ form.thirdparty_payer }}

        </td>

        <td>

          {{ form.ame.label_tag }} :<br>

          {{ form.ame.errors }}

          {{ form.ame }}

        </td>

      </tr>

  </table>

  <table>

      <tr>

        <td>

          {{ form.management_code.label_tag }} :<br>

          {{ form.management_code.errors }}

          {{ form.management_code }}

        </td>

      </tr>

      <tr {% if object.id == request.session.patientrecord_id %}style="display: none;"{%endif%}>

        <td>

          {{ form.addresses.label_tag }} :

          <p id="contact-add-address">

          <a href="#tab=2&newcontact" id="contact-add-address" role="button" title="Ajouter une adresse" onClick="javascript: load_add_address_dialog();">

            <span class="icon-plus" title="Ajouter une adresse"></Span>

            Ajouter une adresse

          </a>

          </p>

          {{ form.addresses.errors }}

          {{ form.addresses }}

        </td>

      </tr>

    </tbody>

  </table>

  <p>

  {{ form.contact_comment.label_tag }}

  {{ form.contact_comment.errors }}

  {{ form.contact_comment }}

  </p>

 </form>

 <div id="address-dlg"></div>