{% extends "hostis-main.html" %} {% block head %} {{ block.super }} {% endblock %} {% block pagehead %} {% include 'hostis-pagehead.html' %} {% endblock %} {% block content %}
{% csrf_token %} {{ patient_info_form.management_form }} {% include 'report-table-header.html' %} {% for frm in patient_info_form %} {% endfor %}
{{ frm.id }}{{ frm.first_name }} {{ frm.middle_name }} {{ frm.last_name }} {{ frm.account }} {{ frm.facility }} {{ frm.active }}    
      
{% csrf_token %}
{{ edit_patient_form.id }}First Name: {{ edit_patient_form.first_name }}    Middle Name: {{ edit_patient_form.middle_name }}    Last Name: {{ edit_patient_form.last_name }}    Suffix: {{ edit_patient_form.suffix }}
SSN: {{ edit_patient_form.ssn }}    Account #: {{ edit_patient_form.account }}    Birth Date: {{ edit_patient_form.birth_date }}    Sex: {{ edit_patient_form.sex }}    Active: {{ edit_patient_form.active }}    Group: {{ edit_patient_form.pat_group }}
Address: {{ edit_patient_form.address }}    Address 2: {{ edit_patient_form.address_2 }}
City: {{ edit_patient_form.city }}    State: {{ edit_patient_form.state }}    Zip: {{ edit_patient_form.zip }}    Phone: {{ edit_patient_form.phone }}
Facility: {{ edit_patient_form.facility }}    Wing: {{ edit_patient_form.wing }}    Floor: {{ edit_patient_form.floor }}    Room: {{ edit_patient_form.room }}    Bed: {{ edit_patient_form.bed }}
Notes: {{ edit_patient_form.notes }}
Admission Date: {{ edit_patient_form.admission_date }}    Discharge Date: {{ edit_patient_form.discharge_date }}    Deceased?: {{ edit_patient_form.death_indicator }}    Deceased Date: {{ edit_patient_form.death_date }}
Nursing Station Id: {{ edit_patient_form.nursing_station_id }}    Nursing Station: {{ edit_patient_form.nursing_station_name }}    Ward Code: {{ edit_patient_form.ward_code }}    Ward Name: {{ edit_patient_form.ward_name }}
Department Code: {{ edit_patient_form.dept_code }}    Department: {{ edit_patient_form.dept_name }}    Payment Type: {{ edit_patient_form.payment_type }}    Insurance Plan: {{ edit_patient_form.insurance_plan }}
{% endblock %}