Your IP : 216.73.216.91
<?php require_once('header.php');?>
<div class="container container-margin">
<div class="mx-auto col-12 col-md-12 col-lg-12">
<form method="post" id="family_service">
<input type="hidden" name="service_id" id="service_id" value="<?php if(isset($_GET['service_id']) && !empty($_GET['service_id'])){echo $_GET['service_id'];}else{echo "-1";}?>">
<input type="hidden" name="family_id" id="family_id" value="<?php if(isset($_GET['family_id']) && !empty($_GET['family_id'])){echo $_GET['family_id'];}?>">
<fieldset>
<h2 class="form-heading">Family Services</h2>
<hr class="colorgraph">
<div class="row form-group" title="Family Information Section | Goto Family List and click services to get family infomation auto filled">
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Father CNIC</label>
<input readonly value="<?php if(isset($_GET['father_cnic']) && !empty($_GET['father_cnic'])){echo $_GET['father_cnic'];}?>" type="text" name="father_cnic" id="father_cnic" class="form-control input-lg" placeholder="Enter Father CNIC">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Father Name</label>
<input readonly type="text" name="father_name" id="father_name" class="form-control input-lg" placeholder="Enter Father Name">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Father Phone</label>
<input readonly type="text" name="father_phone" id="father_phone" class="form-control input-lg" placeholder="Enter Father Phone">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Father Occupation</label>
<input readonly type="text" name="father_occup" id="father_occup" class="form-control input-lg" placeholder="Enter Father Occupation">
</div>
</div>
<div class="row form-group" title="Family Information Section | Goto Family List and click services to get family infomation auto filled">
<div class="col-lg-4 col-md-4 col-sm-12">
<label>Address</label>
<input readonly type="text" name="address" id="address" class="form-control input-lg" placeholder="Enter Address">
</div>
<div class="col-lg-3 col-md-3 col-sm-12">
<label>Mother Name</label>
<input readonly type="text" name="mother_name" id="mother_name" class="form-control input-lg" placeholder="Enter Mother Name">
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label># Of Children</label>
<input readonly type="text" name="children_count" id="children_count" class="form-control input-lg" placeholder="Enter # Of Children">
</div>
<div class="col-lg-2 col-md-2 col-sm-12">
<label>Religion</label>
<input readonly type="text" name="religion" id="religion" class="form-control input-lg" placeholder="Enter Religion">
</div>
<div class="col-lg-1 col-md-1 col-sm-12">
<label>Zakat</label>
<input readonly type="text" name="zakat" id="zakat" class="form-control input-lg" placeholder="Yes/No">
</div>
</div>
<div class="row form-group" title="Family History Section">
<div class="col-lg-6 col-md-6 col-sm-12">
<label>Service</label>
<select class="form-control input-lg" id="service" name="service">
<option value="">Select</option>
<option value="Ration">Ration</option>
<option value="Medical Card">Medical Card</option>
<option value="Eid al-Adha Meat">Eid al-Adha Meat</option>
<option value="Eid Dresses">Eid Dresses</option>
</select>
</div>
<div class="col-lg-6 col-md-6 col-sm-12">
<label>Service Date</label>
<input type="date" name="date" id="date" class="form-control input-lg">
</div>
</div>
<hr>
<hr class="colorgraph thin">
<div class="row form-group">
<div class="col-lg-4 col-md-4 col-sm-12">
<input type="submit" id="fam_submit" class="btn btn-lg btn-primary btn-block llcf-pri" value="Save">
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<input type="button" id="reset" class="btn btn-lg btn-danger btn-block" value="Reset">
</div>
<div class="col-lg-4 col-md-4 col-sm-12">
<a class="btn btn-lg btn-secondary btn-block" href="<?=Config::getConfig('familyServiceGridRedirect')?>">Service History</a>
</div>
</div>
</fieldset>
</form>
</div>
</div>
<?php require_once('footer.php');?>