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<!DOCTYPE html>
<html>
<head>
<!-- Required meta tags -->
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<meta name="google-site-verification" content="">
<meta name="description" content="" />
<meta name="keywords" content="" />
<!-- Title -->
<title>POP Ghana | Basket</title>
<!-- Bootstrap Css -->
<link href="/static/plugins/bootstrap-4.3.1-dist/css/bootstrap.min.css" rel="stylesheet" />
<!-- Dashboard Css -->
<link href="/static/css/style.css" rel="stylesheet" />
<!-- Font-awesome Css -->
<link href="/static/css/icons.css" rel="stylesheet" />
<!--Horizontal Menu-->
<link href="/static/plugins/horizontal/horizontal-menu/animation/fade-down.css" rel="stylesheet" />
<link href="/static/plugins/horizontal/horizontal-menu/horizontal.css" rel="stylesheet" />
<!--Select2 Plugin -->
<link href="/static/plugins/select2/select2.min.css" rel="stylesheet" />
<!-- Owl Theme css-->
<link href="/static/plugins/owl-carousel/owl.carousel.css" rel="stylesheet" />
<!-- Cookie css -->
<link href="/static/plugins/cookie/cookie.css" rel="stylesheet">
<!-- Custom scroll bar css-->
<link href="/static/plugins/scroll-bar/jquery.mCustomScrollbar.css" rel="stylesheet" />
<!-- COLOR-SKINS -->
<link id="theme" rel="stylesheet" type="text/css" media="all" href="/static/color-skins/color-skins/color10.css" />
</head>
<body>
<!--Sliders Section-->
<section>
<div class="bannerimg cover-image bg-background3" data-image-src="/static/images/banners/banner2.jpg">
<div class="header-text mb-0">
<div class="container">
<div class="text-center text-white">
<h1>New Basket</h1>
<ol class="breadcrumb text-center">
<li class="breadcrumb-item"><a href="#">Home</a></li>
<li class="breadcrumb-item"><a href="observation_session.html">Observation Session</a></li>
<li class="breadcrumb-item active text-white" aria-current="page">New Basket</li>
</ol>
</div>
</div>
</div>
</div>
</section>
<!--/Sliders Section-->
<!--Patient data-section-->
<section class="sptb">
<div class="container">
<div class="row ">
<div class="col-lg-12 col-md-12 col-md-12">
<div class="card-header ">
<h3 class="card-title">Patient</h3>
</div>
<div class="card-body">
<div class="row">
<div class="col-lg-9">
<div class="row">
<div class="col-md-6">
<div class="form-group">
<label class="form-label text-dark">Insurance scheme</label>
<select class="form-control custom-select select2-show-search"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="Private Insurance">Private Insurance</option>
<option value="Public Insurance">Public Insurance</option>
<option value="No Insurance">No Insurance</option>
<option value="Undetermined">Undetermined</option>
</select>
</div>
<div class="form-group">
<label class="form-label text-dark">Gender</label>
<select class="form-control custom-select select2-show-search"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Other">Other</option>
</select>
</div>
</div>
<div class="col-md-6">
<div class="form-group">
<label class="form-label text-dark">Age</label>
<input type="number" class="form-control" placeholder="Patient Age"
required>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="card">
<div class="card-header ">
<h3 class="card-title">Drugs</h3>
<div class="card-options">
<a class="btn btn-light btn-sm" href="#"><i class="fa fa-plus"></i> Add Another</a>
</div>
</div>
<div class="card-body">
<div class="form-group">
<label class="form-label text-dark">Initial request</label>
<p id="initial-req-hint" class="input-hint">
Who started the request?
</p>
<select aria-describedby="initial-req-hint"
class="form-control custom-select select2-show-search"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="brand patient">brand patient</option>
<option value="brand prescription">brand prescription</option>
<option value="inn patient">inn patient</option>
<option value="inn prescription">inn prescription</option>
</select>
</div>
<div class="form-group">
<label class="form-label text-dark">Drug sold</label>
<p id="drug-sold-hint" class="input-hint">
Brand name of drug that has been sold?
</p>
<input type="text" aria-describedby="drug-sold-hint" class="form-control"
maxlength="200" required>
</div>
<div class="form-group">
<label class="form-label text-dark">Drug Sale Driver</label>
<p id="drug-sale-driver-hint" class="input-hint">
Who makes the final selection for the purchased product?
</p>
<select aria-describedby="drug-sale-driver-hint"
class="form-control custom-select select2-show-search"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="Patient">Patient</option>
<option value="Pharmacist">Pharmacist</option>
<option value="Prescriber">Prescriber</option>
</select>
</div>
<div class="form-group">
<label class="form-label text-dark">Switched</label>
<p id="switched-hint" class="input-hint">
Was there a switch?
</p>
<div class="form-control">
<label class="custom-control custom-checkbox">
<input type="checkbox" class="custom-control-input"
aria-describedby="switched-hint" name="checkbox" value="checkbox">
<span class="custom-control-label"></span>
</label>
</div>
</div>
<div class="form-group">
<label class="form-label text-dark">Leaked</label>
<p id="leaked-hint" class="input-hint">
Was there a leak?
</p>
<div class="form-control">
<label class="custom-control custom-checkbox">
<input type="checkbox" class="custom-control-input" ame="checkbox"
value="checkbox" required>
<span class="custom-control-label"></span>
</label>
</div>
</div>
<div class="form-group">
<label class="form-label text-dark">Product switched or leaked</label>
<p id="switchleaked-hint" class="input-hint">
What product was switched or leaked?
</p>
<input type="text" aria-describedby="switchedleaked-hint" class="form-control"
maxlength="200" required>
</div>
<div class="form-group">
<label class="form-label text-dark">Reason for switch or leak</label>
<p id="switchleaked-reason-hint" class="input-hint">
Why was there a switch or a leak?
</p>
<select class="form-control custom-select select2-show-search" aria-describedby="switchleaked-reason-hint"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="Not available">Not available</option>
<option value="Price">Price</option>
<option value="Therapeutic Reason">Therapeutic Reason</option>
<option value="Other Reason">Other Reason</option>
</select>
</div>
<div class="form-group">
<label class="form-label text-dark">Form sold</label>
<p id="form-sold-hint" class="input-hint">
What form of drug was sold? liquid,tablet
</p>
<select class="form-control custom-select select2-show-search" aria-describedby="form-sold-hint"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="3">Capsule</option>
<option value="7">Cream</option>
<option value="14">Ear drop</option>
<option value="15">Eye drop</option>
<option value="9">Gel</option>
<option value="12">Inhaler</option>
<option value="6">Injection</option>
<option value="8">Ointment</option>
<option value="10">Patch</option>
<option value="13">Pessary</option>
<option value="16">Powder</option>
<option value="11">Spray</option>
<option value="1">Suppositories</option>
<option value="4">Suspension</option>
<option value="5">Syrup</option>
<option value="2">Tablet</option>
</select>
</div>
<div class="form-group">
<label class="form-label text-dark">Division</label>
<p id="division-hint" class="input-hint">
Was the whole box sold? How was it divided?
</p>
<select aria-describedby="division-hint" class="form-control custom-select select2-show-search"
data-placeholder="Choose one (with searchbox)">
<option value="" selected>---------</option>
<option value="unit">unit</option>
<option value="blister">blister</option>
<option value="box">box</option>
<option value="blister+unit">blister+unit</option>
<option value="box+unit">box+unit</option>
<option value="box+blister">box+blister</option>
</select>
</div>
</div>
</div>
</div>
<div class="float-right mb-4 mb-lg-0">
<a class="btn btn-success w-150" href="#">Finish</a>
</div>
</div>
</div>
</div>
</section>
<!--/Job posts-section-->
<script src="https://www.pywe.org/static/js/jquery.min.js"></script>
<script>
function readURL(input) {
if (input.files && input.files[0]) {
var reader = new FileReader();
reader.onload = function (e) {
$('#blah').attr('src', e.target.result);
}
reader.readAsDataURL(input.files[0]);
}
}
$("#imgInp").change(function () {
readURL(this);
});
</script>
<script>
window.onload = function Load() {
if (navigator.userAgent.match(/iPhone/i) || navigator.userAgent.match(/iPad/i) || navigator.userAgent.match(/Android/i) || navigator.userAgent.match(/Blackberry/i) || navigator.userAgent.match(/WebOs/i)) { // detect mobile browser
window.location.replace("https://gigship.pywe.org/registration/"); // redirect if mobile browser detected
}
}
</script>
<!-- Notification -->
<<<<<<< HEAD
<!-- <a href="#" id="notification"><span class="notification-text">Notifications</span><i
class="fa fa-bell"></i></a> -->
=======
<a href="#" id="notification"><span class="notification-text">Notifications</span><i class="fa fa-bell"></i></a>
>>>>>>> 121b386ef74fc724ec95452c6f1657a68a302c70
<!-- Back to top -->
<a href="#top" id="back-to-top"><i class="fa fa-arrow-up"></i></a>
<!-- JQuery js-->
<script src="/static/js/vendors/jquery-3.2.1.min.js"></script>
<!-- Bootstrap js -->
<script src="/static/plugins/bootstrap-4.3.1-dist/js/popper.min.js"></script>
<script src="/static/plugins/bootstrap-4.3.1-dist/js/bootstrap.min.js"></script>
<!--JQuery Sparkline Js-->
<script src="/static/js/vendors/jquery.sparkline.min.js"></script>
<!-- Circle Progress Js-->
<script src="/static/js/vendors/circle-progress.min.js"></script>
<!-- Star Rating Js-->
<script src="/static/plugins/rating/jquery.rating-stars.js"></script>
<!--Owl Carousel js -->
<script src="/static/plugins/owl-carousel/owl.carousel.js"></script>
<!--Horizontal Menu-->
<script src="/static/plugins/horizontal/horizontal-menu/horizontal.js"></script>
<!--Counters -->
<script src="/static/plugins/counters/counterup.min.js"></script>
<script src="/static/plugins/counters/waypoints.min.js"></script>
<!--JQuery TouchSwipe js-->
<script src="/static/js/jquery.touchSwipe.min.js"></script>
<!--Select2 js -->
<script src="/static/plugins/select2/select2.full.min.js"></script>
<script src="/static/js/select2.js"></script>
<!-- Cookie js -->
<script src="/static/plugins/cookie/jquery.ihavecookies.js"></script>
<script src="/static/plugins/cookie/cookie.js"></script>
<!-- Count Down-->
<script src="/static/plugins/count-down/jquery.lwtCountdown-1.0.js"></script>
<!-- Ion.RangeSlider -->
<script src="/static/plugins/jquery-uislider/jquery-ui.js"></script>
<!-- Custom scroll bar Js-->
<script src="/static/plugins/scroll-bar/jquery.mCustomScrollbar.concat.min.js"></script>
<!-- sticky Js-->
<script src="/static/js/sticky.js"></script>
<!-- Swipe Js-->
<script src="/static/js/swipe.js"></script>
<!-- Scripts Js-->
<script src="/static/js/scripts2.js"></script>
<!-- Ion.RangeSlider -->
<script src="/static/plugins/jquery-uislider/jquery-ui.js"></script>
<!--Showmore Js-->
<script src="/static/js/jquery.showmore.js"></script>
<script src="/static/js/showmore.js"></script>
<!-- Custom Js-->
<script src="/static/js/custom.js"></script>
</body>
</html>