<%@ include file="/includes.jsp"%>
<%@ taglib prefix="smvc" uri="http://www.springframework.org/tags/form"%>
<%@ taglib uri="http://www.springframework.org/tags" prefix="spring"%>
<table border="0" width="100%" cellspacing="0" class="table">				
	<tr>
		<td class="nrltableTitleBarNoBold"> <B>Medical Contact</B>
		</td>
	</tr>	
	<tr>	
		<td   border ="0" align="Center" >
			<table width="100%" border ="0">
				<tr>
					<td align="center" width="30%">
						&#160;
					</td>
					<td align="center" width="40%">
					
						<table width="100%" class="nrlGreytable">
						<tr><td>
						<table width="100%" border="0" >
							<tr class="nrlSpacingtr">
								<td align="left" class="nrlBrownTextBlue">
									<B>Destination*</B>
								</td>
								<td  class="nrlNoLeftBorder">
									<smvc:select path="destination" >
							            <smvc:option value="" label="- - Select a destination - -"/>
							            <smvc:options items="${patientInfo.destinations}" value="destination" label="destination"/>
							        </smvc:select>
								</td>
							</tr>
							<tr class="nrlSpacingtr">
								<td align="left" class="nrlBrownTextBlue">
									<B> Discharged <B> 
								</td>
								<td class="nrlNoLeftBorder"> <smvc:checkbox path="discharged" />
								</td>
							</tr>
							<tr class="nrlSpacingtr">
								<td colspan="2">
									<B> &#160; <B> 
								</td>
							</tr>
							<tr class="nrlSpacingtr">
								<td colspan="2">
									<B> Medical Contacts <B> 
								</td>
							</tr>
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Title </B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="title" />
								</td>
							</tr>							
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Forename*</B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="referoutForename" />
								</td>
							</tr>							
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Surname*</B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="referoutSurname" />
								</td>
							</tr>							
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Address </B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:textarea path="referoutAddress" rows="3" cols="20" />
								</td>
							</tr>						
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Telephone </B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="referoutTelephone" />
								</td>
							</tr>					
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Fax </B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="referoutFax" />
								</td>
							</tr>				
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>email </B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="referoutEmail" />
								</td>
							</tr>			
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Review Date </B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:input path="reviewDate" />
								</td>
							</tr>		
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Reason For Decision*</B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:textarea path="referOutReason" rows="3" cols="20" />
								</td>
							</tr>
							<tr>
								<td align="left" class="nrlBrownTextBlue">
									<B>Acknowledgement</B>
								</td>
								<td class="nrlNoLeftBorder">
									<smvc:radiobutton path="acknowledgement" value="true"/>Yes &#160;&#160;&#160;
        							<smvc:radiobutton path="acknowledgement" value="false"/>NO
								</td>
							</tr>		
							<tr>
								<td align="left" class="nrlBrownTextBlue"> <B>Code</B>
								</td>
								<td >
									<smvc:input path="code" size="8" />
								</td>
							</tr>	
									
							<tr>
								<td align="left" class="nrlBrownTextBlue"><B>Date*</B>
								</td>
								<td ><spring:bind path="referOutDate">
										<input id="referOutDate" name="referOutDate" type="text" size="8"  value="<c:out value="${referralPatientDto.referOutDate}"/>" placeholder="dd/mm/yyyy"/>
									</spring:bind>
									<img title='Click to choose date'
								style='cursor: pointer' src='../images/16x16/date.png'
								id='referOutDate_DateTrigger' />
											<a 
												href="javascript:addNRLEvent('referOutDate', 'Referred out')" 
												title="Add event to calendar">
												<img width="12"  
													src="../calendar/images/16x16/addEvent.png"/>
											</a>
								</td>
							</tr>	
						</table>
						</td></tr>
					  </table>
						
					</td>
					<td align="center" width="30%">
						&#160;
					</td>
				</tr>									
			</table>
		</td>
	</tr>
</table>	
<script src="../webapp.js" 		type="text/javascript"></script>

<script type="text/javascript">
	function dateChanged(calendar) { }
</script>
	
		