diff --git a/iTrust/WebRoot/util/PreRegisterPatient.jsp b/iTrust/WebRoot/util/PreRegisterPatient.jsp index 7f3603959910a7af3b9bdfb5324716010a430a11..e36630e75b2568bd306ae54c12cb0ce7ec2d6c17 100755 --- a/iTrust/WebRoot/util/PreRegisterPatient.jsp +++ b/iTrust/WebRoot/util/PreRegisterPatient.jsp @@ -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">