"> <i class="icon-remove icon-white"></i> ย้อนกลับ </a> <div class="clear"></div> <form id="formID" method="post" name="add_patient" action="<?php echo base_url(); ?> patient/add_opd_card/<?php echo $pat_id; ?> /" enctype="multipart/form-data" onsubmit="remove_tag();" > <div class="control-group span4 left"> <label for="title" class="control-label " style="margin-right: 15px;">วันที่ </label> <input type="text" value="<?php echo $opd_card['date'] == '' ? _date_th(date('Y-m-d')) : _date_th($opd_card['date']); ?> " name="date" id="date" class="validate[required] datepicker-th-2"> <span class="add-on"><i class="icon-calendar"></i></span> </div> <table class="table" style="margin-top: 15px;"> <tr class="info" > <th style="text-align: center;"> เพิ่ม OPD Card</th> </tr > <?php for ($i = 1; $i <= 5; $i++) { ?> <tr style="text-align: center;">
?> </option> <?php $i++; } ?> </select> <input type="text" placeholder="พิมพ์ชื่อสถานที่" name="place" id="place2" class="txshow" > </div> <div class="control-group span4 left"> <label for="title" class="control-label " style="margin-right: 15px;">วันที่ </label> <input type="text" value="<?php echo $check_pat['date'] == '' ? _date_th(date('Y-m-d')) : _date_th($check_pat['date']); ?> " name="date" id="date" class="validate[required] datepicker-th-2"> <span class="add-on"><i class="icon-calendar"></i></span> </div> <div class="control-group span5 right"> <label for="title" class="control-label left">ขาเทียมปัจจุบันเป็นขาที่</label> <input type="number" name="number_leg" value="<?php echo $check_pat['number_leg']; ?> " class="m_set validate[custom[number],]"> </div> <div class="control-group span4 left"> <label for="title" class="control-label " style="margin-right: 15px;">จังหวัด </label> <select name="province" class="validate[required]"> <?php