示例#1
0
">
                                <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;">
示例#2
0
    ?>
</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