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> </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>
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