81 lines
4.8 KiB
HTML
81 lines
4.8 KiB
HTML
{% extends "layouts/source_user_base.html" %}
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{% load i18n static %}
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{% block title %}{% trans "Contact PX Team" %} - PX360{% endblock %}
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{% block content %}
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<div class="p-6 md:p-8 bg-gradient-to-br from-light to-blue-50 min-h-screen">
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<div class="mb-6">
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<a href="{% url 'px_sources:source_user_communication_requests' %}" class="inline-flex items-center gap-2 text-slate hover:text-navy transition text-sm font-semibold">
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<i data-lucide="arrow-left" class="w-4 h-4"></i> {% trans "Back to My Requests" %}
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</a>
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</div>
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<div class="max-w-2xl mx-auto">
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<div class="bg-white rounded-2xl border-2 border-slate-200 shadow-lg p-8">
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<div class="mb-6">
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<h1 class="text-2xl font-bold text-navy flex items-center gap-3">
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<i data-lucide="phone-outgoing" class="w-6 h-6 text-teal-600"></i>
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{% trans "Contact PX Team" %}
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</h1>
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<p class="text-slate text-sm mt-1">{% trans "Request the PX team to communicate with a patient" %}</p>
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</div>
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<form method="post">
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{% csrf_token %}
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<div class="mb-5">
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<label class="block text-xs font-bold text-slate uppercase tracking-wider mb-2">{% trans "Patient Name" %}</label>
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<input type="text" name="patient_name" class="w-full px-4 py-3 border-2 border-slate-200 rounded-xl text-sm focus:ring-2 focus:ring-navy/20 focus:border-navy outline-none"
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placeholder="{% trans 'Patient full name' %}">
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</div>
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<div class="grid grid-cols-2 gap-4 mb-5">
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<div>
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<label class="block text-xs font-bold text-slate uppercase tracking-wider mb-2">{% trans "Patient Phone" %}</label>
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<input type="text" name="patient_phone" class="w-full px-4 py-3 border-2 border-slate-200 rounded-xl text-sm focus:ring-2 focus:ring-navy/20 focus:border-navy outline-none"
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placeholder="{% trans 'Phone number' %}">
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</div>
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<div>
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<label class="block text-xs font-bold text-slate uppercase tracking-wider mb-2">{% trans "Patient MRN" %}</label>
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<input type="text" name="patient_mrn" class="w-full px-4 py-3 border-2 border-slate-200 rounded-xl text-sm focus:ring-2 focus:ring-navy/20 focus:border-navy outline-none"
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placeholder="{% trans 'Medical Record Number' %}">
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</div>
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</div>
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<div class="mb-5">
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<label class="block text-xs font-bold text-slate uppercase tracking-wider mb-2">{% trans "Reason" %}</label>
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<select name="reason" class="w-full px-4 py-3 border-2 border-slate-200 rounded-xl text-sm focus:ring-2 focus:ring-navy/20 focus:border-navy outline-none">
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<option value="complaint_followup">{% trans "Complaint Follow-up" %}</option>
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<option value="general_inquiry" selected>{% trans "General Inquiry" %}</option>
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<option value="feedback">{% trans "Feedback Sharing" %}</option>
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<option value="urgent">{% trans "Urgent Matter" %}</option>
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<option value="other">{% trans "Other" %}</option>
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</select>
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</div>
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<div class="mb-6">
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<label class="block text-xs font-bold text-slate uppercase tracking-wider mb-2">
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{% trans "Message" %} <span class="text-red-500">*</span>
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</label>
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<textarea name="message" rows="4" required class="w-full px-4 py-3 border-2 border-slate-200 rounded-xl text-sm focus:ring-2 focus:ring-navy/20 focus:border-navy outline-none resize-none"
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placeholder="{% trans 'Describe what the patient needs...' %}"></textarea>
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</div>
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<div class="px-6 md:px-8 py-4 bg-slate-50 border-t border-slate-100 flex gap-3">
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<button type="submit" class="inline-flex items-center gap-2 px-6 py-3 bg-blue-600 text-white rounded-xl font-semibold hover:bg-blue-700 transition">
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<i data-lucide="check" class="w-5 h-5"></i>
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{% trans "Send Request" %}
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</button>
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<a href="{% url 'px_sources:source_user_communication_requests' %}"
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class="inline-flex items-center gap-2 px-6 py-3 bg-white border-2 border-slate-200 text-slate-700 rounded-xl font-semibold hover:bg-slate-50 transition">
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<i data-lucide="x" class="w-5 h-5"></i>
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{% trans "Cancel" %}
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</a>
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</div>
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</form>
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</div>
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</div>
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</div>
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{% endblock %}
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