{% extends "layouts/base.html" %} {% load i18n %} {% load static %} {% block title %}{% if is_create %}Create{% else %}Edit{% endif %} Feedback - PX360{% endblock %} {% block extra_css %} {% endblock %} {% block content %}

{% if is_create %}Create New Feedback{% else %}Edit Feedback{% endif %}

Cancel
{% csrf_token %} {% if form.non_field_errors %} {% endif %}
Patient/Contact Information
{{ form.is_anonymous }}
{% if form.is_anonymous.errors %}
{{ form.is_anonymous.errors }}
{% endif %}
{{ form.patient }} {% if form.patient.help_text %}
{{ form.patient.help_text }}
{% endif %} {% if form.patient.errors %}
{{ form.patient.errors }}
{% endif %}
Feedback Details
{{ form.feedback_type }} {% if form.feedback_type.errors %}
{{ form.feedback_type.errors }}
{% endif %}
{{ form.title }} {% if form.title.errors %}
{{ form.title.errors }}
{% endif %}
{{ form.message }}
Please provide detailed feedback
{% if form.message.errors %}
{{ form.message.errors }}
{% endif %}
{{ form.category }} {% if form.category.errors %}
{{ form.category.errors }}
{% endif %}
{{ form.subcategory }} {% if form.subcategory.errors %}
{{ form.subcategory.errors }}
{% endif %}
Rate your experience from 1 to 5 stars
{% if form.rating.errors %}
{{ form.rating.errors }}
{% endif %}
{{ form.priority }} {% if form.priority.errors %}
{{ form.priority.errors }}
{% endif %}
Organization Information
{{ form.hospital }} {% if form.hospital.errors %}
{{ form.hospital.errors }}
{% endif %}
{{ form.department }}
Select the department related to this feedback (optional)
{% if form.department.errors %}
{{ form.department.errors }}
{% endif %}
{{ form.physician }}
Select the physician mentioned in this feedback (optional)
{% if form.physician.errors %}
{{ form.physician.errors }}
{% endif %}
{{ form.encounter_id }}
Related encounter ID if applicable (optional)
{% if form.encounter_id.errors %}
{{ form.encounter_id.errors }}
{% endif %}
Cancel
{% endblock %} {% block extra_js %} {% endblock %}