Register.jsp
001 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
002 <%page contentType="text/html;charset=UTF-8" language="java" %>
003 <%taglib uri="/WEB-INF/struts-bean.tld" prefix="bean" %>
004 <%taglib uri="/WEB-INF/struts-html.tld" prefix="html" %>
005 <%taglib uri="/WEB-INF/sslext.tld" prefix="sslext"%>
006 <%page import="com.bea.medrec.utils.MedRecWebAppUtils"%>
007 
008 <html:html>
009 <head>
010   <html:base/>
011   <title><bean:message key="title.MedRec"/></title>
012   <link rel="stylesheet" type="text/css" href="stylesheet.css">
013 </head>
014 <body bgColor="white" leftMargin="0" topMargin="0" rightMargin="0" MARGINHEIGHT="0" MARGINwidth="0">
015 
016 <!-- Patient Header Begin -->
017 <table width="100%" cellpadding="0" cellspacing="0" border="0">
018 <tr>
019   <td bgcolor="#006666" align=left>
020     <img src="images/patient_top_banner3.gif">
021   </td>
022   <td bgcolor="#006666">
023     <div class="pageheaderpatient">
024       <bean:message key="page.title.patient.registration"/>
025     </div>
026   </td>
027 </tr>
028 <tr>
029   <td bgcolor="#E9F4F0">
030     <img src="images/patient_banner_photo.jpg">
031   </td>
032   <td bgcolor="#E9F4F0">
033     <br/>
034   </td>
035 </tr>
036 </table>
037 <!-- Patient Header End -->
038 
039 <!-- Padding for Content Start -->
040 <table width="100%" border="0" cellspacing="1" cellpadding="10">
041 <tr><td>
042 
043 <!-- Content -->
044 <sslext:form method="<%=MedRecWebAppUtils.getHttpMethod()%>" action="/register.do" focus="userBean.username">
045 <table cellSpacing="0" cellPadding=10 border="1">
046 <tr>
047   <td>
048     <table cellSpacing="1" cellPadding="1" align="center" border="0">
049     <tr>
050       <td colspan="5"><b><bean:message key="message.all.fields.required"/></b><br/></td>
051     </tr>
052     <tr>
053       <td class="label"><bean:message key="Email"/></td>
054       <td>
055         <html:text
056           name="registrationBean"
057           property="userBean.username"
058           size="20"
059           maxlength="45"
060           redisplay="false"
061           tabindex="1"/>
062       </td>
063       <td>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</td>
064       <td class="label"><bean:message key="Address"/></td>
065       <td></td>
066     </tr>
067     <tr>
068       <td></td>
069       <td align="left">
070         <html:messages id="error" property="userBean.username">
071           <bean:write name="error" filter="false"/>
072         </html:messages>
073       </td>
074     </tr>
075     <tr>
076       <td class="label"><bean:message key="Password"/> <br/><font size=1pt>(8-10 chars)</font></td>
077       <td>
078         <html:password
079           name="registrationBean"
080           property="userBean.password"
081           size="20"
082           maxlength="10"
083           redisplay="false"
084           tabindex="2"/>
085       </td>
086       <td></td>
087       <td class="label"><bean:message key="Street"/></td>
088       <td>
089         <html:text
090           name="registrationBean"
091           property="patientBean.address.streetName1"
092           size="20"
093           maxlength="60"
094           tabindex="10"/>
095       </td>
096     </tr>
097     <tr>
098       <td></td>
099       <td align="left">
100         <html:messages id="error" property="userBean.password">
101           <bean:write name="error" filter="false"/>
102         </html:messages>
103       </td>
104       <td></td>
105       <td></td>
106       <td align="left">
107         <html:messages id="error" property="patientBean.address.streetName1">
108           <bean:write name="error" filter="false"/>
109         </html:messages>
110       </td>
111     </tr>
112     <tr>
113       <td class="label"><bean:message key="FirstName"/></td>
114       <td>
115         <html:text
116           name="registrationBean"
117           property="patientBean.firstName"
118           size="20"
119           maxlength="60"
120           tabindex="3"/>
121       </td>
122       <td></td>
123       <td></td>
124       <td>
125         <html:text
126           name="registrationBean"
127           property="patientBean.address.streetName2"
128           size="20"
129           maxlength="60"
130           tabindex="11"/>
131       </td>
132     </tr>
133     <tr>
134       <td></td>
135       <td align="left">
136         <html:messages id="error" property="patientBean.firstName">
137           <bean:write name="error" filter="false"/>
138         </html:messages>
139       </td>
140       </td>
141     </tr>
142     <tr>
143       <td class="label"><bean:message key="MiddleName"/></td>
144       <td>
145         <html:text
146           name="registrationBean"
147           property="patientBean.middleName"
148           size="20"
149           maxlength="60"
150           tabindex="4"/>
151       </td>
152       <td></td>
153       <td><b><bean:message key="City"/></b></td>
154       <td>
155         <html:text
156           name="registrationBean"
157           property="patientBean.address.city"
158           size="20"
159           maxlength="60"
160           tabindex="12"/>
161       </td>
162     </tr>
163     <tr>
164       <td></td>
165       <td align="left">
166         <html:messages id="error" property="patientBean.middleName">
167           <bean:write name="error" filter="false"/>
168         </html:messages>
169       </td>
170       </td>
171       <td></td>
172       <td></td>
173       <td align="left">
174         <html:messages id="error" property="patientBean.address.city">
175           <bean:write name="error" filter="false"/>
176         </html:messages>
177       </td>
178       </td>
179     </tr>
180     <tr>
181       <td><b><bean:message key="LastName"/></b></td>
182       <td>
183         <html:text
184           name="registrationBean"
185           property="patientBean.lastName"
186           size="20"
187           maxlength="60"
188           tabindex="5"/>
189       </td>
190       <td></td>
191       <td class="label"><bean:message key="State"/></td>
192       <td>
193         <html:text
194           name="registrationBean"
195           property="patientBean.address.state"
196           size="2"
197           maxlength="2"
198           tabindex="13"/>
199       </td>
200     </tr>
201     <tr>
202       <td></td>
203       <td align="left">
204         <html:messages id="error" property="patientBean.lastName">
205           <bean:write name="error" filter="false"/>
206         </html:messages>
207       </td>
208       </td>
209       <td></td>
210       <td></td>
211       <td align="left">
212         <html:messages id="error" property="patientBean.address.state">
213           <bean:write name="error" filter="false"/>
214         </html:messages>
215       </td>
216       </td>
217     </tr>
218     <tr>
219       <td class="label"><bean:message key="Gender"/></td>
220       <td>
221         <html:select name="registrationBean" property="patientBean.gender" tabindex="6">
222           <html:option value=""><bean:message key="ChooseGender"/></html:option>
223           <html:option value="dashes">-------------</html:option>
224           <html:option value="Male" key="Male"/>
225           <html:option value="Female" key="Female"/>
226         </html:select>
227       </td>
228       <td></td>
229       <td class="label"><bean:message key="Zip"/></td>
230       <td>
231         <html:text
232           name="registrationBean"
233           property="patientBean.address.zipCode"
234           size="20"
235           maxlength="10"
236           tabindex="14"/>
237       </td>
238     </tr>
239     <tr>
240       <td></td>
241       <td align="left">
242         <html:messages id="error" property="patientBean.gender">
243           <bean:write name="error" filter="false"/>
244         </html:messages>
245       </td>
246       </td>
247       <td></td>
248       <td></td>
249       <td align="left">
250         <html:messages id="error" property="patientBean.address.zipCode">
251           <bean:write name="error" filter="false"/>
252         </html:messages>
253       </td>
254       </td>
255     </tr>
256     <tr>
257       <td class="label"><bean:message key="DOB"/><br/><font size=1pt>(mm/dd/yyyy)</font></td>
258       <td>
259         <html:text
260           name="registrationBean"
261           property="patientBean.dob"
262           size="10"
263           maxlength="10"
264           tabindex="7"/>
265       </td>
266       <td></td>
267       <td class="label"><bean:message key="Country"/></td>
268       <td>
269         <html:text
270           name="registrationBean"
271           property="patientBean.address.country"
272           size="20"
273           maxlength="60"
274           tabindex="15"/>
275       </td>
276     </tr>
277     <tr>
278       <td></td>
279       <td align="left">
280         <html:messages id="error" property="patientBean.dob">
281           <bean:write name="error" filter="false"/>
282         </html:messages>
283       </td>
284       </td>
285       <td></td>
286       <td></td>
287       <td align="left">
288         <html:messages id="error" property="patientBean.address.country">
289           <bean:write name="error" filter="false"/>
290         </html:messages>
291       </td>
292       </td>
293     </tr>
294     <tr>
295       <td class="label"><bean:message key="SSN"/><br/><font size=1pt>(xxxxxxxxx)</font></td>
296       <td>
297         <html:text
298           name="registrationBean"
299           property="patientBean.ssn"
300           size="9"
301           maxlength="9"
302           tabindex="8"/>
303       </td>
304       <td></td>
305       <td></td>
306       <td></td>
307     </tr>
308     <tr>
309       <td></td>
310       <td align="left">
311         <html:messages id="error" property="patientBean.ssn">
312           <bean:write name="error" filter="false"/>
313         </html:messages>
314       </td>
315       </td>
316     </tr>
317     <tr>
318       <td class="label"><bean:message key="Phone"/><br/><font size=1pt>(xxx-xxx-xxxx)</font></td>
319       <td>
320         <html:text
321           name="registrationBean"
322           property="patientBean.phone"
323           size="12"
324           maxlength="12"
325           tabindex="9"/>
326       </td>
327       <td></td>
328       <td></td>
329       <td></td>
330     </tr>
331     <tr>
332       <td></td>
333       <td align="left">
334         <html:messages id="error" property="patientBean.phone">
335           <bean:write name="error" filter="false"/>
336         </html:messages>
337       </td>
338       </td>
339     </tr>
340     <tr>
341       <td></td>
342       <td>
343         <br/>
344         <table>
345           <tr><td>
346             <html:submit property="action" tabindex="16" styleClass="profileButton">
347               <bean:message key="button.Register"/>
348             </html:submit>
349           </td>
350           <td>
351             <html:link tabindex="17" styleClass="cancelbutton" forward="medrec.startpage">
352               <bean:message key="button.Cancel"/>
353             </html:link>
354           </td></tr>
355         </table>
356       </td>
357       <td></td>
358       <td></td>
359       <td></td>
360     </tr>
361     </table>
362   </td>
363 </tr>
364 </table>
365 </sslext:form>
366   <!-- Content END -->
367 </td></tr>
368 </table>
369 </body>
370 </HTML>
371 </html:html>