{% extends 'dashboard_screen/base.html' %} {% block content %}

New Order Entry Form

{% if Step == 0 %}
{% csrf_token %} {% if Patient %} {% endif %} {% endif %} {% if Step == 1 %} {% csrf_token %} {% if Patient %} {% endif %} {% endif %} {% if Step == 2 %} {% csrf_token %} {% if Patient %} {% endif %} {% endif %} {% if Step == 3 %} {% csrf_token %} {% if Patient %} {% endif %} {% endif %} {% if Patient %} {% else %} {% endif %}

Patient Information

{% if Step == 0 %} {% if Patient %}

Update Patient

{% else %}

Adding New Patient

{% endif %}
Collection Date:(*)
Client Name / Client Code(*)
Attending Physician Name (*)
Patient External ID:
First Name: (*)
Last Name: (*)
DOB: mm/dd/yy (*)
Address:
Address 2:
SSN:(*)
Phone:
City:
Zip Code:
State:
Gender:(*)
Ethnicity:

Enter payor information

Responsible Party (if different from patient)

Relationship To Patient:

{% endif %}

Select Examen

{% if Step == 1 %}

You can select Multiple Exams.

{% endif %}

Test Information2

{% if Step == 2 %}
{% endif %}

Confirmation

{% if Step == 3 %}
{% endif %}
{{ message }}
{% if Step == 0 %} {% endif %} {% if Step == 1 %} {% endif %} {% if Step == 2 %} {% endif %} {% if Step == 3 %} {% endif %}
{% endblock %}