@model MALDFGASSURANCE.Models.ASSURE
@{
    ViewBag.Title = "FICHE SOINS";
    Layout = "~/views/shared/_layout.cshtml";
}
<style>
    @@media print {
        body {
            visibility: hidden;
        }

        .print-container {
            visibility: visible;
            margin-top:-50px;
            
        }

        @@page {
            margin: 0;
        }
        .table-bordered th, .table-bordered td {
            border: 1px solid #000 !important;
        }
    }
    .table-bordered th, .table-bordered td {
        border: 1px solid #000;
    }
</style>
<!--begin::Entry-->
<div class="d-flex flex-column-fluid">
    <!--begin::Container-->
    <div class="container print-container">
        <!-- begin::Card-->
        <div class="card card-custom overflow-hidden">
            <div class="card-body p-0">
                <!-- begin: Invoice-->
                <!-- begin: Invoice header-->
                <div class="row justify-content-center bgi-size-cover bgi-no-repeat pt-2 py-mt-0 px-md-0" style="background-image: url(MALDFGASSURANCE/assets/media/bg/bg-6.png)">
                    <div class="col-md-10">
                        <div class="d-flex justify-content-between pb-10 flex-column flex-md-row">
                            <h1 class="display-4 text-primary font-weight-boldest mb-10" style="padding-top:50px;">FICHE CONSULTATION</h1>
                            <div class="d-flex flex-column align-items-md-start px-0" style="padding-top:50px;">
                                <!--begin::Logo-->
                                <a href="#" class="mb-5">
                                    <img src="MALDFGASSURANCE/assets/media/logos/logo1.png" alt="LOGO" />
                                </a>
                                <!--end::Logo-->
                                <span class="text-dark-75 d-flex flex-column align-items-md-start opacity-70">
                                    <span>Abidjan - Plateau 01 BP 228 Abidjan 01</span>
                                    <span>Tél : +225.27.20.30.63 / Fax : +225.27.20.30.63.64</span>
                                    <span>Cél : +225.01.01.31.91.66 / 07.47.18.25.47</span>
                                    <span>Email : assum.sante@ldfgroupe.com</span>
                                </span>
                            </div>
                        </div>
                        <div style="font-size:17px">N°&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Date:</div>
                        <div class="border-bottom w-100"></div>
                        <!--<div class="d-flex justify-content-between text-dark-75 pt-6">
                            <div class="d-flex flex-column flex-root">
                                <span class="font-weight-bolde mb-2r">DATA</span>
                                <span class="opacity-70">Dec 12, 2017</span>
                            </div>
                            <div class="d-flex flex-column flex-root">
                                <span class="font-weight-bolder mb-2">INVOICE NO.</span>
                                <span class="opacity-70">GS 000014</span>
                            </div>

                        </div>-->

                    </div>
                </div>
                <!-- end: Invoice header-->
                <div class="row justify-content-center py-8 px-8 py-md-5 px-md-0">
                    <div class="col-md-10">
                        <form class="form">
                            <div class="form-group">
                                <label>
                                    Centre de Soins<span class="svg-icon svg-icon-primary svg-icon-xl">
                                        <span class="svg-icon svg-icon-primary svg-icon-2x">
                                            <!--begin::Svg Icon | path:C:\wamp64\www\keenthemes\themes\metronic\theme\html\demo3\dist/../src/media/svg/icons\Files\File-plus.svg--><svg xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" width="24px" height="24px" viewBox="0 0 24 24" version="1.1">
                                                <g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
                                                    <polygon points="0 0 24 0 24 24 0 24" />
                                                    <path d="M5.85714286,2 L13.7364114,2 C14.0910962,2 14.4343066,2.12568431 14.7051108,2.35473959 L19.4686994,6.3839416 C19.8056532,6.66894833 20,7.08787823 20,7.52920201 L20,20.0833333 C20,21.8738751 19.9795521,22 18.1428571,22 L5.85714286,22 C4.02044787,22 4,21.8738751 4,20.0833333 L4,3.91666667 C4,2.12612489 4.02044787,2 5.85714286,2 Z" fill="#000000" fill-rule="nonzero" opacity="0.3" />
                                                    <path d="M11,14 L9,14 C8.44771525,14 8,13.5522847 8,13 C8,12.4477153 8.44771525,12 9,12 L11,12 L11,10 C11,9.44771525 11.4477153,9 12,9 C12.5522847,9 13,9.44771525 13,10 L13,12 L15,12 C15.5522847,12 16,12.4477153 16,13 C16,13.5522847 15.5522847,14 15,14 L13,14 L13,16 C13,16.5522847 12.5522847,17 12,17 C11.4477153,17 11,16.5522847 11,16 L11,14 Z" fill="#000000" />
                                                </g>
                                            </svg><!--end::Svg Icon-->
                                        </span>
                                        <!--end::Svg Icon-->
                                    </span>
                                </label>
                                <input type="text" class="form-control form-control-solid" placeholder="Centre de soins" style="border:1px solid black" />
                            </div>

                            <!--begin::Form-->
                            <form class="form">

                                <div class="form-group row">
                                    <div class="col-lg-10 col-sm-10">
                                        <label>Société:</label>
                                        <input type="email" class="form-control" placeholder="Entrer nom de la société"  style="border:1px solid black"/>
                                        <span class="form-text text-black">Veuillez saisir le nom de Société</span>
                                    </div>
                                    <div class="col-lg-6 col-sm-6">
                                        <label>Salarié:</label>
                                        <div class="input-group">
                                            @*<div class="input-group-prepend">
                                                <span class="input-group-text">
                                                    <i class="la la-user"></i>
                                                </span>
                                            </div>*@
                                            <input type="text" class="form-control" placeholder="Entrer le salarié" style="border:1px solid black"/>
                                        </div>
                                        <span class="form-text text-black">Veuillez saisir le nom du Salarié</span>
                                    </div>
                                    <div class="col-lg-6 col-sm-6">
                                        <label>Matricule:</label>
                                        <input type="email" class="form-control" placeholder="Entrer Matricule" style="border:1px solid black"/>
                                        <span class="form-text text-dark">Veuillez saisir le matricule</span>
                                    </div>

                                </div>
                                <div class="form-group row">
                                    <div class="col-lg-6 col-sm-6">
                                        <label>Patient</label>
                                        <input type="email" class="form-control" placeholder="Entrer le nom du patient" style="border:1px solid black" />
                                        <span class="form-text text-dark">Veuillez entrer le  nom du patient</span>
                                    </div>
                                    <div class="col-lg-6 col-sm-6">
                                        <label>Matricule:</label>
                                        <div class="input-group">
                                            @*<div class="input-group-prepend">
                                                <span class="input-group-text">
                                                    <i class="la la-info-circle"></i>
                                                </span>
                                            </div>*@
                                            <input type="text" class="form-control" placeholder="N° Matricule" style="border:1px solid black" />
                                        </div>
                                        <span class="form-text text-dark">Veuillez saisir le matricule</span>
                                    </div>
                                </div>

                            </form>
                            <!--end::Form-->
                            <!--end: Code-->
                        </form>
                    </div>
                </div>

                <!-- begin: Invoice body-->
                <div class="row justify-content-center py-8 px-8 py-md-5 px-md-0">
                    <div class="col-md-10">
                        <div class="table-responsive">
                            <table class="table table-bordered">
                                <thead class="thead-green" style="border-bottom: 2px solid black;">
                                    <tr>
                                        <th class="pl-0 font-weight-bold text-center text-dark text-uppercase">Prescripteur</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">Code d'affection</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">Acte</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">Montant brut (CFA)</th>
                                        <th class="text-center pr-0 font-weight-bold text-dark text-uppercase">Montant à régler (CFA)</th>
                                    </tr>
                                </thead>
                                <tbody>
                                    <tr class="font-weight-boldest border-bottom-0 font-size-lg">
                                        <td class="border-top-0 pl-0 pt-10"></td>
                                        <td class="border-top-0 text-right pt-10"></td>
                                        <td class="border-top-0 text-right pt-10"></td>
                                        <td class="text-danger border-top-0 pr-0 pt-10 text-right"></td>
                                        <td class="text-right pt-10"></td>
                                    </tr>
                                </tbody>
                            </table>
                        </div>
                    </div>
                </div>
                <!-- end: Invoice body-->
                <!-- begin: Invoice body-->
                <div class="row justify-content-center py-8 px-8 py-md-5 px-md-0">
                    <div class="col-md-10">
                        <div class="table-responsive">
                            <table class="table table-bordered">
                                <thead class="thead-green" style="border-bottom: 2px solid black;">
                                    <tr>
                                        <th class="pl-0 font-weight-bold text-center text-dark text-uppercase">DERMATO-ALLERGOLOGIE</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">GYNECO-NEURO-PSYCHIATRE</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">ORL-OPHTALMOLOGIE</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">AUTRES</th>
                                    </tr>
                                </thead>
                                <tbody>
                                    <tr class="font-size-xss border-bottom-0 ">
                                        <td class="border-top-0 pl-0 pt-10">
                                            <ul>
                                                <li>Allergènes-Antiseptiques locaux</li>
                                                <li>Anticianéiques-Antiséborrhéiques</li>
                                                <li>Antisudoraux-Antiparasitaire externes</li>
                                                <li>Antialopeciques-Troubles de la pigmentation...</li>
                                            </ul>
                                        </td>
                                        <td class="border-top-0 text-left pt-10">
                                            <ul>
                                                <li>Allergènes-Antiseptiques locaux</li>
                                                <li>Anticianéiques-Antiséborrhéiques</li>
                                                <li>Antisudoraux-Antiparasitaire externes</li>
                                                <li>Antialopeciques-Troubles de la pigmentation...</li>
                                            </ul>
                                        </td>
                                        <td class="border-top-0 text-left pt-10">
                                            <ul>
                                                <li>Allergènes-Antiseptiques locaux</li>
                                                <li>Anticianéiques-Antiséborrhéiques</li>
                                                <li>Antisudoraux-Antiparasitaire externes</li>
                                                <li>Antialopeciques-Troubles de la pigmentation...</li>
                                            </ul>
                                        </td>
                                        <td class="text-dark border-top-0 pr-0 pt-10 text-left">
                                            <ul>
                                                <li>Allergènes-Antiseptiques locaux</li>
                                                <li>Anticianéiques-Antiséborrhéiques</li>
                                                <li>Antisudoraux-Antiparasitaire externes</li>
                                                <li>Antialopeciques-Troubles de la pigmentation...</li>
                                            </ul>
                                        </td>
                                    </tr>
                                </tbody>
                            </table>
                        </div>
                    </div>
                </div>
                <!-- end: Invoice body-->
                <!-- begin: Invoice body-->
                <div class="row justify-content-center py-8 px-8 py-md-5 px-md-0">
                    <div class="col-md-10">
                        <div class="table-responsive">
                            <table class="table table-bordered">
                                <thead class="thead-green" style="border-bottom: 2px solid black;">
                                    <tr>
                                        <th class="pl-0 font-weight-bold text-center text-dark text-uppercase">Médicament</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase">Posologie</th>
                                        <th class="text-center font-weight-bold text-dark text-uppercase" style="width: 250px">Quantité (en lettre)</th>
                                        <th class="text-center pr-0 font-weight-bold text-dark text-uppercase" style="width: 200px">Prix</th>
                                    </tr>
                                </thead>
                                <tbody>
                                    <tr class="font-weight-boldest font-size-lg">
                                        <td class="pl-0 pt-10"></td>
                                        <td class="text-right pt-10"></td>
                                        <td class="text-right pt-10"></td>
                                        <td class="text-danger pr-0 pt-10 text-right"></td>
                                    </tr>
                                    <tr class="font-weight-boldest border-bottom-0 font-size-lg">
                                        <td class="border-top-0 pl-0 pt-10"></td>
                                        <td class="border-top-0 text-right pt-10"></td>
                                        <td class="border-top-0 text-right pt-10"></td>
                                        <td class="text-danger border-top-0 pr-0 pt-10 text-right"></td>
                                    </tr>
                                    <tr class="font-weight-boldest border-bottom-0 font-size-lg">
                                        <td class="border-top-0 pl-0 pt-10"></td>
                                        <td class="border-top-0 text-right pt-10"></td>
                                        <td class="border-top-0 text-right pt-10"></td>
                                        <td class="text-danger border-top-0 pr-0 pt-10 text-right"></td>
                                    </tr>

                                </tbody>
                                <tfoot>
                                    <tr class=" border-bottom-0 font-size-lg">
                                        <td colspan="2" rowspan="3" class="pt-1 font-size-basse" style=" border:none;border-right:1px solid; font-size:14px;color:black">
                                            NB:-Délai de validité de la prescription=1semaine<br />-A présenter à la MUTUELLE SANTE LDFG en même temps que la facture<br />mensuelle au plus tard le 5 de chaque mois sous peine sde forclusion
                                        </td>
                                        <td class="font-weight-boldest border-left-0 border-top-0 text-right">Sous Total</td>
                                        <td></td>
                                    </tr>
                                    <tr class=" border-bottom-0 font-size-lg align-items-md-end">
                                       
                                        <td class="font-weight-boldest border-top-0 border-left-0 text-right pt-1">Ticket modérateur</td>
                                        <td></td>
                                    </tr>
                                    <tr class="font-weight-boldest border-bottom-00 font-size-lg ">
                                        
                                        <td class="border-top-0 border-left-0 text-right pt-1" style="border-bottom:1px solid black">Total</td>
                                        <td style="border-bottom:1px solid black"></td>
                                    </tr>
                                </tfoot>

                            </table>
                        </div>
                    </div>
                </div>
                <!-- end: Invoice body-->
                <!-- begin: Invoice action-->
                <div class="row justify-content-center py-8 px-8 py-md-5 px-md-0">
                    <div class="col-md-3 align-text-top text-center" style="width: 250px;height: 70px;border: 1px solid black;border-radius:5px;margin: auto; font-size:10px">
                        signture et cachet medecin executant
                    </div>
                    <div class="col-md-2 align-text-top text-center" style="width: 150px;height: 70px;border: 1px solid black;border-radius:5px;margin: auto; font-size:10px">
                        signture et cachet Pharmacien
                    </div>
                    <div class="col-md-2 align-text-top text-center" style="width: 150px;height: 70px;border: 1px solid black;border-radius:5px;margin: auto; font-size:10px">
                        signture Patient
                    </div>
                    <div class="col-md-2 align-text-top text-center" style="width: 150px;height: 70px;border: none;border-radius:5px;margin: auto; font-size:10px">
                        <img src="MALDFGASSURANCE/assets/media/bg/ldf.png" width="70" alt="logo"/>
                    </div>




                </div>
                <!-- end: Invoice action-->
                <!-- end: Invoice-->
            </div>
        </div>
        <!-- end::Card-->
    </div>

    <!--end::Container-->
</div>
<button type="button" style="margin-right:5px; margin-top:10px" class="btn btn-primary font-weight-bold" onclick="window.print();">Imprimer la fiche</button>
<!--end::Entry-->

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