calebasse / calebasse / dossiers / templates / dossiers / patientcontact_form.html @ 26c60057
1 |
{% load widget_tweaks %} |
---|---|
2 |
|
3 |
<form action="{{ request.get_full_path }}" method="post"> |
4 |
{% csrf_token %} |
5 |
<table>
|
6 |
<tbody>
|
7 |
<tr>
|
8 |
<p>
|
9 |
</p>
|
10 |
<td>
|
11 |
{{ form.first_name.label_tag }} :<br>
|
12 |
{{ form.first_name }} |
13 |
{{ form.first_name.errors }} |
14 |
</td>
|
15 |
<td>
|
16 |
{{ form.last_name.label_tag }} :<br>
|
17 |
{{ form.last_name }} |
18 |
{{ form.last_name.errors }} |
19 |
</td>
|
20 |
<td>
|
21 |
{{ form.gender.label_tag }} :<br>
|
22 |
{{ form.gender }} |
23 |
{{ form.gender.errors }} |
24 |
</td>
|
25 |
</tr>
|
26 |
<tr>
|
27 |
<td>
|
28 |
{{ form.mobile.label_tag }} :<br>
|
29 |
{{ form.mobile }} |
30 |
{{ form.mobile.errors }} |
31 |
</td>
|
32 |
<td>
|
33 |
{{ form.email.label_tag }} :<br>
|
34 |
{{ form.email }} |
35 |
{{ form.email.errors }} |
36 |
</td>
|
37 |
</tr>
|
38 |
<tr>
|
39 |
<td>
|
40 |
{{ form.birthdate.label_tag }} :<br>
|
41 |
{{ form.birthdate }} |
42 |
{{ form.birthdate.errors }} |
43 |
</td>
|
44 |
<td>
|
45 |
{{ form.social_security_id.label_tag }} :<br>
|
46 |
{{ form.social_security_id }} |
47 |
{{ form.social_security_id.errors }} |
48 |
</td>
|
49 |
<td>
|
50 |
{{ form.key.label_tag }} :<br>
|
51 |
{{ form.key }} |
52 |
{{ form.key.errors }} |
53 |
</td>
|
54 |
</tr>
|
55 |
<tr>
|
56 |
<td>
|
57 |
{{ form.begin_rights.label_tag }} :<br>
|
58 |
{{ form.begin_rights }} |
59 |
{{ form.begin_rights.errors }} |
60 |
</td>
|
61 |
<td>
|
62 |
{{ form.end_rights.label_tag }} :<br>
|
63 |
{{ form.end_rights }} |
64 |
{{ form.end_rights.errors }} |
65 |
</td>
|
66 |
<td>
|
67 |
{{ form.twinning_rank.label_tag }} :<br>
|
68 |
{{ form.twinning_rank }} |
69 |
{{ form.twinning_rank.errors }} |
70 |
</td>
|
71 |
</tr>
|
72 |
<tr>
|
73 |
<td>
|
74 |
{{ form.healt_fund.label_tag }} :<br>
|
75 |
{{ form.healt_fund }} |
76 |
{{ form.healt_fund.errors }} |
77 |
</td>
|
78 |
<td>
|
79 |
{{ form.healt_center.label_tag }} :<br>
|
80 |
{{ form.healt_center }} |
81 |
{{ form.healt_center.errors }} |
82 |
</td>
|
83 |
</tbody>
|
84 |
</table>
|
85 |
<p>
|
86 |
{{ form.addresses.label_tag }} |
87 |
{{ form.addresses }} |
88 |
{{ form.addresses.errors }} |
89 |
</p>
|
90 |
<p>
|
91 |
{{ form.contact_comment.label_tag }} |
92 |
{{ form.contact_comment }} |
93 |
{{ form.contact_comment.errors }} |
94 |
</p>
|
95 |
</form>
|