<form class="prescription" action="?action=update_prescription" method="POST">
<input type="hidden" name="prescription" value="${mpx[prescription]}">
+<table class="type"><tbody>
+ <tr>
+ <th>$(l10n doctor)</th>
+ <th>$(l10n dentist)</th>
+ <th>$(l10n noprescription)</th>
+ <th>$(l10n altpractition)</th>
+ </tr>
+ <tr>
+ <td class="selfpaid doctor">
+ <input type=radio name=presctype id=doctor_selfpaid value=doctor_selfpaid>
+ <label for=doctor_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ <td class="selfpaid dentist">
+ <input type=radio name=presctype id=dentist_selfpaid value=dentist_selfpaid>
+ <label for=dentist_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ <td class="selfpaid noprescription">
+ <input type=radio name=presctype id=noprescription_selfpaid value=noprescription_selfpaid>
+ <label for=noprescription_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ <td class="selfpaid altpractition">
+ <input type=radio name=presctype id=altpractition_selfpaid value=altpractition_selfpaid>
+ <label for=altpractition_selfpaid>$(l10n selfpaid)</label>
+ </td>
+ </tr>
+ <tr>
+ <td class="private doctor">
+ <input type=radio name=presctype id=doctor_private value=doctor_private>
+ <label for=doctor_private>$(l10n private)</label>
+ </td>
+ <td class="private dentist">
+ <input type=radio name=presctype id=dentist_private value=dentist_private>
+ <label for=dentist_private>$(l10n private)</label>
+ </td>
+ <td class="private noprescription">
+ </td>
+ <td class="private altpractition">
+ <input type=radio name=presctype id=altpractition_private value=altpractition_private>
+ <label for=altpractition_private>$(l10n private)</label>
+ </td>
+ </tr>
+ <tr>
+ <td class="compulsory doctor">
+ <input type=radio name=presctype id=doctor_compulsory value=doctor_compulsory>
+ <label for=doctor_compulsory>$(l10n compulsory)</label>
+ </td>
+ <td class="compulsory dentist">
+ <input type=radio name=presctype id=dentist_compulsory value=dentist_compulsory>
+ <label for=dentist_compulsory>$(l10n compulsory)</label>
+ </td>
+ <td class="compulsory noprescription">
+ </td>
+ <td class="compulsory altpractition">
+ </td>
+ </tr>
+</tbody></table>
+
<fieldset class="baseinfo">
<label for="insurance">$(l10n insurance)</label>
<input id="insurance" name="insurance" value="${mpx[insurance]}" placeholder="$(l10n insurance)">
</fieldset>
<fieldset class="misc">
-<h1>$(l10n therapy_prescription)</h1>
+<h1 id="${mpx[prescription]}">$(l10n therapy_prescription)</h1>
<label for="addcontrib">$(l10n addcontrib)</label>
<input id="addcontrib" name="addcontrib" value="${mpx[addcontrib]}" placeholder="$(l10n addcontrib)">
-<input type="checkbox" id="contribconfirm" name="contribconfirm" value="true" ${mpx[contribconfirm]:+checked}>
<label for="contribconfirm">$(l10n contribconfirm)</label>
+<input id="contribconfirm" name="contribconfirm" value="${mpx[contribconfirm]}" placeholder="$(l10n contribconfirm)">
+<input type="checkbox" id="contribreceipt" name="contribreceipt" value="true" ${mpx[contribreceipt]:+checked}>
+<label for="contribreceipt">$(l10n contribreceipt)</label>
</fieldset>
+<input type="checkbox" id="prescreviewed" name="prescreviewed" value="true" ${mpx[prescreviewed]:+checked}>
+<label for="prescreviewed">$(l10n prescreviewed)</label>
+
<fieldset class="catalogue">
<h2>$(l10n prescription_by_catalogue)</h2>
<input type="radio" id="prescfirst" name="prescno" value="first" $(check "$mpx[prescno]" first)>
<input type="radio" id="prescfollow2" name="prescno" value="follow2" $(check "$mpx[prescno]" follow2)>
<label for="prescfollow2">$(l10n prescfollow2)</label>
<br>
-<input type="radio" id="presccontinual" name="prescno" value="continual" $(check "$mpx[prescno]" continual)>
-<label for="presccontinual">$(l10n presccontinual)</label>
-<br>
<input type="radio" id="prescother" name="prescno" value="other" $(check "$mpx[prescno]" other)>
<label for="prescother">$(l10n prescother)</label>
+<br>
+<input type="radio" id="presccontinual" name="prescno" value="continual" $(check "$mpx[prescno]" continual)>
+<label for="presccontinual">$(l10n presccontinual)</label>
<br>
<input type="checkbox" id="grouptherapy" name="grouptherapy" value="true" ${mpx[grouptherapy]:+checked}>
<input id="quantity_weekly1" name="quantity_weekly1" value="${mpx[quantity_weekly1]}" placeholder="$(l10n quantity_weekly)">
<br>
+<p class="indicator_codes">
<label for="indicator">$(l10n indicator)</label>
<input id="indicator" name="indicator" value="${mpx[indicator]}" placeholder="$(l10n indicator)">
<br>
<label for="icd10">$(l10n icd10)</label>
<input id="icd10" name="icd10" value="${mpx[icd10]}" placeholder="$(l10n icd10)">
+</p>
+<br>
+<p class="indicator_reading">
+<label for="indicator_reading">$(l10n indicator_reading)</label>
+<textarea id="indicator_reading" name="indicator_reading" placeholder="$(l10n indicator_reading)">${mpx[indicator_reading]}</textarea>
+</p>
</fieldset>
-<input type="checkbox" id="prescreviewed" name="prescreviewed" value="true" ${mpx[prescreviewed]:+checked}>
-<label for="prescreviewed">$(l10n prescreviewed)</label>
-
<fieldset class="controls">
<button type="submit" name="action" value="save">$(l10n save)</button>
<button type="submit" name="action" value="cancel">$(l10n cancel)</button>