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90 lines
3.8 KiB
90 lines
3.8 KiB
2 years ago
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<?php
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/**
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* contacts new.php
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*
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* @package OpenEMR
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* @link http://www.open-emr.org
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* @author andres_paglayan <andres_paglayan>
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* @author sunsetsystems <sunsetsystems>
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* @author cornfeed <jdough823@gmail.com>
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* @author fndtn357 <fndtn357@gmail.com>
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* @author Brady Miller <brady.g.miller@gmail.com>
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* @author Daniel Ehrlich <daniel.ehrlich1@gmail.com>
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* @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
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* @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
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* @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com>
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* @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com>
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* @copyright Copyright (c) 2018 Brady Miller <brady.g.miller@gmail.com>
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* @copyright Copyright (c) 2018 Daniel Ehrlich <daniel.ehrlich1@gmail.com>
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* @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
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*/
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?>
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<!-- Form generated from formsWiz -->
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<?php
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require_once("../../globals.php");
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require_once("$srcdir/api.inc");
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use OpenEMR\Common\Csrf\CsrfUtils;
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use OpenEMR\Core\Header;
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formHeader("Form: contacts");
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?>
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<html><head>
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<?php Header::setupHeader(); ?>
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</head>
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<body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
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<form method=post action="<?php echo $rootdir;?>/forms/contacts/save.php?mode=new" name="my_form">
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<input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
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<span class="title">Contacts</span><br /><br />
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<table>
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<tr>
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<td valign=top>
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<table>
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<tr><td><span class=text>OD Base Curve: </span></td><td><input size=4 type="text" name="od_base_curve" value="" ></td></tr>
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<tr><td><span class=text>OD Sphere: </span></td><td><input size=4 type="text" name="od_sphere" value="" ></td></tr>
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<tr><td><span class=text>OD Cylinder: </span></td><td><input size=4 type="text" name="od_cylinder" value="" ></td></tr>
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<tr><td><span class=text>OD Axis: </span></td><td><input size=4 type="text" name="od_axis" value="" ></td></tr>
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<tr><td><span class=text>OD Diameter: </span></td><td><input size=4 type="text" name="od_diameter" value="" ></td></tr>
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</table>
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</td>
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<td valign=top>
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<table>
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<tr><td><span class=text>OS Base Curve: </span></td><td><input size=4 type="text" name="os_base_curve" value="" ></td></tr>
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<tr><td><span class=text>OS Sphere: </span></td><td><input size=4 type="text" name="os_sphere" value="" ></td></tr>
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<tr><td><span class=text>OS Cylinder: </span></td><td><input size=4 type="text" name="os_cylinder" value="" ></td></tr>
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<tr><td><span class=text>OS Axis: </span></td><td><input size=4 type="text" name="os_axis" value="" ></td></tr>
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<tr><td><span class=text>OS Diameter: </span></td><td><input size=4 type="text" name="os_diameter" value="" ></td></tr>
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</table>
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</td>
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</tr>
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</table>
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<table>
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<tr><td><span class=text>Material: </span></td><td><input size=4 type="text" name="material" value="" ></td>
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<td><span class=text>Color: </span></td><td><input size=4 type="text" name="color" value="" ></td>
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<td><span class=text>Bifocal Type: </span></td><td><input size=4 type="text" name="bifocal_type" value="" ></td>
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<td><span class=text>Add: </span></td><td><input size=4 type="text" name="add_value" value="" ></td>
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<td><span class=text>V/A Far: </span></td><td><input size=4 type="text" name="va_far" value="" ></td>
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<td><span class=text>V/A Near: </span></td><td><input size=4 type="text" name="va_near" value="" ></td>
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</tr>
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</table>
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<table>
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<tr>
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<td valign=top>
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<span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea><br />
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</td>
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</tr>
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</table>
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<br />
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<a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
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<br />
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<a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
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onclick="top.restoreSession()">[Don't Save]</a>
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</form>
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<?php
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formFooter();
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?>
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