<!DOCTYPE html><html lang="id"><head>
<meta charset="utf-8"><meta name="viewport" content="width=device-width,initial-scale=1">
<title>Pasien Baru</title>
<link rel="stylesheet" href="<?= base_url('assets/adminlte/dist/css/adminlte.min.css');?>">
</head><body class="hold-transition sidebar-mini">
<div class="container p-3">
  <h4><i class="fas fa-user-plus"></i> Pasien Baru</h4>
  <form class="row g-2" method="post" action="<?= site_url('pasien-baru/simpan');?>">
    <div class="col-md-3"><label class="form-label">No RM</label><input name="rme_no" class="form-control" required></div>
    <div class="col-md-5"><label class="form-label">Nama Lengkap</label><input name="nama_lengkap" class="form-control" required></div>
    <div class="col-md-2"><label class="form-label">Tgl Lahir</label><input type="date" name="tanggal_lahir" class="form-control"></div>
    <div class="col-md-2"><label class="form-label">JK</label>
      <select name="jenis_kelamin" class="form-select"><option value="L">L</option><option value="P">P</option></select>
    </div>
    <div class="col-12"><label class="form-label">Alamat</label><textarea name="alamat" class="form-control"></textarea></div>
    <div class="col-md-4"><label class="form-label">NIK</label><input name="nik" class="form-control"></div>
    <div class="col-md-4"><label class="form-label">No Telp</label><input name="no_telp" class="form-control"></div>
    <div class="col-md-4"><label class="form-label">Email</label><input type="email" name="email" class="form-control"></div>
    <div class="col-12 d-flex gap-2 mt-2">
      <button class="btn btn-primary"><i class="fas fa-save"></i> Simpan</button>
      <a href="<?= site_url('registrasi');?>" class="btn btn-secondary">Batal</a>
    </div>
  </form>
</div>
<script src="<?= base_url('assets/adminlte/plugins/jquery/jquery.min.js');?>"></script>
<script src="<?= base_url('assets/adminlte/plugins/bootstrap/js/bootstrap.bundle.min.js');?>"></script>
</body></html>
