<div class="row">
    <div class="container">

        <ol class="breadcrumb">
            <li><a href="#">العيادات</a></li>
            <li><a href="rb_doc_kashf.php?do=">عيادات</a></li>
            <li class="active">اضافة كشف</li>
        </ol>


        <div class="panel panel-default panel-m">
            <div class="panel-heading">
                <h3 class="panel-title">اضافة كشف</h3>
            </div>
            <div class="panel-body">


                {literal}
                <form class="nameToBeChecked form-horizontal" id="rb_doc_kashf" enctype="multipart/form-data" role="form" action="rb_doc_kashf.php?do=add" method="post" >

                    {/literal}

                    <input type="hidden" name="kashId" value="{$id}"/>
                    <input type="hidden" name="clientId" value="{$get->customerid}"/>
                    <input type="hidden" name="docSel" value="{$get->doctorid}"/>
                    <input type="hidden" name="kashfdate" value="{$get->kashfdate}"/>

                    <div class="form-group">
                        <div class="form-group">
                            <label class="col-lg-6 control-label"> اسم العميل :     {$get->clientname} </label>
                        </div>
                    </div>


                    <div class="form-group">
                        <div class="form-group">
                            <label class="col-lg-6 control-label"> اسم الطبيب :  {$get->docname} </label>
                        </div>
                    </div>
                    <!-- =================================================   -->


                    <div class="form-group">

                        <div class="col-lg-6">


                            <table class="table-black">
                                <tr>

                                    <td style="padding-right: 259px;padding-top: 30px;font-size: 20px;padding-bottom: 13px;" colspan="6"> <label class="sr-only">Left Eye</label> </td>

                                </tr>
                                <tr>

                                    <td></td>
                                    <td style="padding-right: 36px;" > <label class="sr-only">L-va</label> </td>
                                                               
                                    <td style="padding-right: 36px;" > <label class="sr-only">L-prism</label> </td>
   
                                    <td style="padding-right: 36px;" > <label class="sr-only">L-axis</label> </td>

                                    <td style="padding-right: 22px;" > <label class="sr-only">L-cylinder</label> </td>

                                    <td style="padding-right: 22px;" >   <label class="sr-only">L-sphere</label> </td>


                                </tr>
                                <tr>


                                    <td style="border: 1px solid black;"> <label style="margin: 5px;" class="sr-only">المسافة</label> </td>




                                    <td style="border: 1px solid black;"> <input  required="required"  type="text" name="D_Lva"   class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="D_Lprism"    class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input  required="required" type="text" name="D_Laxis"     class="form-control positiveNo" /></td>
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="D_Lcylinder"   class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input required="required" type="text"  name="D_Lsphere"   class="form-control checknumintfolat realNo" /></td>

                                </tr>
                                <tr>


                                    <td style="border: 1px solid black;"> <label style="margin: 5px;" class="sr-only">القراءة</label> </td>





                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="N_Lva"     class="form-control checknumintfolat realNo" /></td>
                                   
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="N_Lprism"    class="form-control checknumintfolat realNo" /></td>

                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="N_Laxis"    class="form-control positiveNo" /></td>
 
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="N_Lcylinder"    class="form-control checknumintfolat realNo" /></td>

                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="N_Lsphere"   class="form-control checknumintfolat realNo" /></td>

                                </tr>
                            </table>
                        </div>


                        <div class="col-lg-6">



                            <table class="table-black">
                                <tr>

                                    <td  style="padding-right: 194px;padding-top: 30px;font-size: 20px;padding-bottom: 13px;" colspan="6"> <label class="sr-only">Right Eye</label>  </td>

                                </tr>
                                <tr>
                                    <td style="padding-right: 36px;" > <label class="sr-only">R-va</label> </td>
                                   <td style="padding-right: 36px;" > <label class="sr-only">R-prism</label> </td>
                                  
                                    <td style="padding-right: 36px;" > <label class="sr-only">R-axis</label> </td>

                                    <td style="padding-right: 22px;" > <label class="sr-only">R-cylinder</label> </td>

                                    <td style="padding-right: 22px;" > <label class="sr-only">R-sphere</label> </td>

                                    <td></td>

                                </tr>
                                <tr>
                                    <td style="border: 1px solid black;">  <input  required="required"  type="text" name="D_Rva"    class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input  required="required"  type="text" name="D_Rprism"   class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input  required="required"  type="text" name="D_Raxis"    class="form-control positiveNo" /></td>

                                    <td style="border: 1px solid black;">  <input required="required"  type="text" name="D_Rcylinder"    class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input  required="required" type="text" name="D_Rsphere"   class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;text-align: left;"> <label style="margin: 5px;"  class="sr-only">Distance</label> </td>
                                </tr>
                                <tr>


                                    <td style="border: 1px solid black;">   <input required="required"   type="text" name="N_Rva"   class="form-control checknumintfolat realNo" /></td>
                                                               
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="N_Rprism"   class="form-control checknumintfolat realNo" /></td>

                                    <td style="border: 1px solid black;"> <input  required="required" type="text" name="N_Raxis"    class="form-control positiveNo" /></td>

                                    <td style="border: 1px solid black;">  <input required="required"  type="text" name="N_Rcylinder"   class="form-control checknumintfolat realNo" /></td>
             
                                    <td style="border: 1px solid black;">  <input  required="required" type="text" name="N_Rsphere"     class="form-control checknumintfolat realNo" /></td>

                                    <td style="border: 1px solid black;text-align: left;"> <label style="margin: 5px;" class="sr-only">Near</label> </td>

                                </tr>
                            </table>



                        </div>


                        <div class="col-lg-5" style="padding-left: 0px;">
                            <table style="border: 1px solid black;margin-right:62px;width: 83%;" class="table-black">
                                <tr>
                                    <td style="padding-right: 70px;padding-top: 10px;border: 1px solid black;" ><label class="sr-only">Add</label> </td>
                                    <td style="padding-right: 70px;padding-top: 10px;border: 1px solid black;" > <label class="sr-only">Biofocal</label> </td>
                                </tr>
                                <tr>
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="ladd"   class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="lbiofocal"    class="form-control checknumintfolat realNo" /></td>
                                </tr>
                            </table>
                        </div>

                        <div class="col-lg-3">
                            <table style="border: 1px solid black; margin-top: 5px;width: 100%;" class="table-black">
                                <tr>
                                    <td style="border: 1px solid black;">  <input required="required"  type="text" name="pd"    class="form-control positiveNo" /></td>
                                    <td style="border: 1px solid black;text-align: left;"> <label style="margin: 5px;" class="sr-only">PD</label> </td>
                                </tr>
                                <tr>
                                    <td style="border: 1px solid black;">  <input  required="required"  type="text" name="bvd"   class="form-control positiveNo" /></td>
                                    <td style="border: 1px solid black; text-align: left;"> <label style="margin: 5px;" class="sr-only">BVD</label> </td>
                                </tr>
                            </table>
                        </div>

                        <div class="col-lg-4">
                            <table style="border: 1px solid black;margin-left: 65px;" class="table-black">
                                <tr>
                                    <td style="padding-right: 45px;padding-top: 10px;border: 1px solid black;" ><label class="sr-only">Add</label> </td>
                                    <td style="padding-right: 45px;padding-top: 10px;border: 1px solid black;" > <label class="sr-only">Biofocal</label> </td>
                                </tr>
                                <tr>
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="radd"   class="form-control checknumintfolat realNo" /></td>
                                    <td style="border: 1px solid black;"> <input required="required"  type="text" name="rbiofocal"    class="form-control checknumintfolat realNo" /></td>
                                </tr>
                            </table>
                        </div>

                        <div class="col-lg-12">
                            <table style="margin-top: 5px;width: 100%;border: 1px solid black;" class="table-black">
                                <tr>
                                    <td style="border: 1px solid black;"> <label style="margin: 5px;" class="sr-only">ملاحظات</label> </td>
                                    <td style="border: 1px solid black;">  <input  required="required"  type="text" name="notes"    class="form-control" /></td>
                                </tr>

                            </table>
                        </div>
                    </div>



                    <!-- =================================================   -->



                    <div class="form-group">
                        <div  class="col-lg-4">
                            <button style="    margin-left: -704px;margin-top: 20px;" type="button"  id="docKashfS" class="btn btn-primary pull-left ">حفظ </button>
                        </div>
                    </div>


                </form>
            </div>
        </div>




    </div>
</div>



{literal}

<script type="text/javascript">
    var name = new Spry.Widget.ValidationTextField("name");
    var sprytextfield1 = new Spry.Widget.ValidationTextField("sprytextfield1", "real");
    var sprytextfield3 = new Spry.Widget.ValidationTextField("sprytextfield3");
    var spryselect1 = new Spry.Widget.ValidationSelect("spryselect1", {invalidValue: "-1"});



</script>
<script type="text/javascript">
    var sprytextfield2 = new Spry.Widget.ValidationTextField("sprytextfield2");
    $(document).ready(function () {
        
    
    });
    
    
    
</script>


{/literal}


