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Commit 3d5f58a3 authored by xuechen5's avatar xuechen5
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Make "*" red for required fields.

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iTrust/WebRoot/util/PreRegisterPatient.jsp
+ 109
− 91
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......@@ -114,100 +114,118 @@ to recover the password.</div>
<br />
<br />
<table class="fTable">
<tr>
<th colspan=2 style="text-align:center">Pre-registered Patient Information</th>
</tr>
<tr>
<td class="subHeaderVertical">First name:</td>
<td><input type="text" name="firstName" required> *</td>
</tr>
<tr>
<td class="subHeaderVertical">Last Name:</td>
<td><input type="text" name="lastName" required> *</td>>
</tr>
<tr>
<td class="subHeaderVertical">Email:</td>
<td><input type="text" name="email" required> *</td>
</tr>
<tr>
<td class="subHeaderVertical">Password:</td>
<td><input type="password" name="password" id ="password" required> *</td>
</tr>
<tr>
<td class="subHeaderVertical">Verify Password:</td>
<td><input type="password" name="verifyPassword" id = "verifyPassword" required> *</td>
</tr>
<tr>
<td class="subHeaderVertical">Address:</td>
<td> <input name="streetAddress1" type="text"><br />
<input name="streetAddress2" type="text"></td>
</tr>
<tr>
<td class="subHeaderVertical">City:</td>
<td> <input name="city" type="text"></td>
</tr>
<tr>
<td class="subHeaderVertical">State:</td>
<td><itrust:state name="state" value="AK" /></td>
</tr>
<tr>
<td class="subHeaderVertical">Zip:</td>
<td> <input type="text" name="zip" maxlength="10" size="10"></td>
</tr>
<tr>
<td class="subHeaderVertical">Phone:</td>
<td> <input type="text" name="phone" size="12" maxlength="12"></td>
</tr>
<tr>
<td class="subHeaderVertical">Height:</td>
<td><input type="text" name="height"></td>
</tr>
<tr>
<td class="subHeaderVertical">Weight:</td>
<td><input type="text" name="weight"></td>
</tr>
<tr>
<td class="subHeaderVertical">Smoker:</td>
<td><input type="radio" id="smoker_yes" name="isSmoker" value="1">
<tr>
<th colspan=3 style="text-align:center">Pre-registered Patient Information</th>
</tr>
<tr>
<td class="subHeaderVertical">First name:</td>
<td><input type="text" name="firstName" required></td>
<td style="font-size: 16pt; text-align:left; color:red">*</td>
</tr>
<tr>
<td class="subHeaderVertical">Last Name:</td>
<td><input type="text" name="lastName" required></td>
<td style="font-size: 16pt; text-align:left; color:red">*</td>
</tr>
<tr>
<td class="subHeaderVertical">Email:</td>
<td><input type="text" name="email" required></td>
<td style="font-size: 16pt; text-align:left; color:red">*</td>
</tr>
<tr>
<td class="subHeaderVertical">Password:</td>
<td><input type="password" name="password" id ="password" required></td>
<td style="font-size: 16pt; text-align:left; color:red">*</td>
</tr>
<tr>
<td class="subHeaderVertical">Verify Password:</td>
<td><input type="password" name="verifyPassword" id = "verifyPassword" required></td>
<td style="font-size: 16pt; text-align:left; color:red">*</td>
</tr>
<tr>
<td class="subHeaderVertical">Address:</td>
<td> <input name="streetAddress1" type="text"><br />
<input name="streetAddress2" type="text"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">City:</td>
<td> <input name="city" type="text"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">State:</td>
<td><itrust:state name="state" value="AK" /></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Zip:</td>
<td> <input type="text" name="zip" maxlength="10" size="10"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Phone:</td>
<td> <input type="text" name="phone" size="12" maxlength="12"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Height:</td>
<td><input type="text" name="height"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Weight:</td>
<td><input type="text" name="weight"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Smoker:</td>
<td><input type="radio" id="smoker_yes" name="isSmoker" value="true">
<label for="smoker_yes">Yes</label>
<br>
<input type="radio" id="smoker_no" name="isSmoker" value="0" checked>
<label for="smoker_no">No</label><br>
<br />
<input type="radio" id="smoker_no" name="isSmoker" value="false">
<label for="smoker_no">No</label><br />
</td>
</tr>
<br/>
<tr>
<th colspan=2 style="text-align:center">Insurance Information</th>
</tr>
<tr>
<td class="subHeaderVertical">Insurance Provider Name:</td>
<td> <input type="text" name="icName"></td>
</tr>
<tr>
<td class="subHeaderVertical">Insurance Provider Address:</td>
<td><input name="icAddress1" type="text"><br />
<input name="icAddress2" type="text"></td>
</tr>
<tr>
<td class="subHeaderVertical">City:</td>
<td> <input name="icCity" type="text"></td>
</tr>
<tr>
<td class="subHeaderVertical">State:</td>
<td><itrust:state name="icState" value="AK" /></td>
</tr>
<tr>
<td class="subHeaderVertical">Zip:</td>
<td> <input type="text" name="icZip" maxlength="10" size="10"></td>
</tr>
<tr>
<td class="subHeaderVertical">Insurance Provider Phone:</td>
<td><input type="text" name="icPhone"></td>
</tr>
<td> </td>
</tr>
<br/>
<tr>
<th colspan=3 style="text-align:center">Insurance Information</th>
</tr>
<tr>
<td class="subHeaderVertical">Insurance Provider Name:</td>
<td> <input type="text" name="icName"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Insurance Provider Address:</td>
<td><input name="icAddress1" type="text"><br />
<input name="icAddress2" type="text"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">City:</td>
<td> <input name="icCity" type="text"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">State:</td>
<td><itrust:state name="icState" value="AK" /></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Zip:</td>
<td> <input type="text" name="icZip" maxlength="10" size="10"></td>
<td> </td>
</tr>
<tr>
<td class="subHeaderVertical">Insurance Provider Phone:</td>
<td><input type="text" name="icPhone"></td>
<td> </td>
</tr>
</table>
<br />
<input type="submit" style="font-size: 16pt; font-weight: bold;" value="Patient Pre-Register" id="submit_preregister">
......
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