{% extends "site.html" %}


{% block head %}
    {{ block.super }}
    <script>
        $(function () {
            $("#cancel").click(function() {
                window.location.href = "{% url 'site:settings-manage-pharmacy' %}";
            })
        });
    </script>
{% endblock %}

{% block pagehead %}
    {% include 'pagehead.html' %}
{% endblock %}

{% block content %}
    <form name="pharmacyInfoSettingsForm" id="pharmacyInfoSettingsForm" class="form-horizontal" method="POST">
    {% csrf_token %}
        <div class="well well-small">
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_name">Pharmacy Name: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_name }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_address">Address Line 1: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_address }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_address_2">Address Line 2: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_address_2 }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_city">City: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_city }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_state">State: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_state }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_zip">Zip Code: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_zip }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_phone">Phone: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_phone }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_fax">Fax: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_fax }}
                </div>
            </div>
            <div class="control-group" style="margin-bottom: 5px;">
                <label class="control-label" for="id_pharmacy_dea">DEA Number: </label>
                <div class="controls">
                    {{ pharmacy_info_form.pharmacy_dea }}
                </div>
            </div>
            <button class="btn" id="apply-pharmacy-info-settings" name="apply-pharmacy-info-settings">Update</button>&nbsp;&nbsp;&nbsp;&nbsp;
            <button class="btn cancel" type="button" id="cancel" name="cancel">Cancel</button>
        </div>
    </form>
{% endblock %}