@extends('master')

<script type="text/javascript">
	$(document).foundation();
</script>

@section('content')

	<div class="row">
        <div class="large-12 columns">
            <div class="row">
                <div class="small-12 medium-12 large-12 columns">
                    <h4>Laboratories Registration</h4>
                </div>
            </div>
        </div>
    </div>

    <div class="row">

    	<form action="{{{ URL::to('lab') }}}" method="post" data-abide>

			<div class="small-12 medium-12 large-12  columns">

				<div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Lab Name</label>
	                  <input type="text" id="lab_name" name="lab_name" placeholder="" required />
	                  <small class="error" data-error-message>Lab Name is required.</small>
	                </div>
	            </div>

	            <div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Description</label>
	                  <input type="text" id="description" name="description" placeholder="" required />
	                  <small class="error" data-error-message>Description is required.</small>
	                </div>
	            </div>

	            <div class="row">
	            	<div class="small-12 medium-4 large-4 columns">
	            		<label>HL7 version</label>
	            		<input type="text" id="HL7_version" name="HL7_version" placeholder="" required />
	                	<small class="error" data-error-message>HL7 version is required.</small>
	            	</div>
	            	<div class="small-12 medium-4 large-4 columns">
	            		<label>Host</label>
	            		<input type="text" id="host" name="host" placeholder="" required />
	                	<small class="error" data-error-message>Host is required.</small>
	            	</div>
	            	<div class="small-12 medium-4 large-4 end columns">
	            		<label>Port</label>
	            		<input type="text" id="port" name="port" placeholder="" required />
	                	<small class="error" data-error-message>Port is required.</small>
	            	</div>
	            </div>

	            <div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Email</label>
	                  <input type="email" id="lab_email" name="lab_email" placeholder="" required />
	                  <small class="error" data-error-message>Email is required.</small>
	                </div>
	            </div>

	            <div class="row">
	                <div class="small-12 medium-12 large-12 columns">
	                  <label>Preferred</label>
	                  <input type="text" id="preferred" name="preferred" placeholder="" required />
	                  <small class="error" data-error-message>Preferred is required.</small>
	                </div>
	            </div>

	            <div class="row">
	            	
	            	<div class="small-12 large-6 columns">
	            		<h4>Hl7 Available Segments</h4>
	            		<label for="">Message Header <input type="checkbox" checked onclick="return false"></label>
	            		<label for="">ORU <input type="checkbox"></label>
	            		<label for="">ORM <input type="checkbox"></label>
	            		<label for="">ACK <input type="checkbox"></label>
	            		<label for="">DG1 <input type="checkbox"></label>
	            		<label for="">OBX <input type="checkbox"></label>
	            		<label for="">ETC <input type="checkbox"></label>
	            	</div>
	         
	            </div>

	            <div class="row">
	                <div class="small-12 medium-6 large-6 columns">
	                  <button class="expand">Save</button>
	                </div>
	                <div class="small-12 medium-6 large-6 end columns">
	                  <a href="{{{URL::to('/lab')}}}" class="button expand">Cancel</a>
	                </div>
	            </div>

			</div>

		</form>

	</div>


@stop