Friday, February 25, 2011
ASP.NET - aspx - page for data input and some code - In Progress
<%@ Page Title="Home Page" Language="VB" MasterPageFile="~/Site.Master" AutoEventWireup="false"
CodeFile="Copy of EnterData.aspx.vb" Inherits="_Default" %>
<asp:Content ID="HeaderContent" runat="server" ContentPlaceHolderID="HeadContent">
</asp:Content>
<asp:Content ID="BodyContent" runat="server" ContentPlaceHolderID="MainContent">
<h2>
Welcome to All Ear Doctors Hearing Aids
<asp:Button ID="Button1" runat="server" Text="Enter"
style="z-index: 1; left: 550px; top: 134px; position: absolute" />
</h2>
<table width="900" border="1">
<tr>
<td width="300"><h3 align="center">Patient</h3></td>
<td width="300"><h3 align="center">Insurance</h3></td>
<td width="300"><h3 align="center">Financials</h3></td>
</tr>
</table>
<table width="900" border="1">
<tr>
<td width="150px">First Name</td>
<td width="150px">
<asp:TextBox ID="FName" runat="server" Width="150px"></asp:TextBox>
</td>
<td width="150px">Date of Visit</td>
<td width="150px"> <asp:TextBox ID="DateVisit" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Transaction Date</td>
<td width="150px"><asp:TextBox ID="TDate" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">Middle Name</td>
<td width="150px"><asp:TextBox ID="LName" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Hearing Aid Benefit</td>
<td width="150px"><asp:TextBox ID="HABenefit" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Gross Sale</td>
<td width="150px"><asp:TextBox ID="GrossSale" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">Last Name</td>
<td width="150px"><asp:TextBox ID="RefBy" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Benefit By Whom</td>
<td width="150px"> <asp:TextBox ID="HABenWhom" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">COGS</td>
<td width="150px"><asp:TextBox ID="COGS" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">Referred By</td>
<td width="150px"><asp:TextBox ID="Age" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Insurer</td>
<td width="150px"> <asp:TextBox ID="HMO" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Brand</td>
<td width="150px"><asp:TextBox ID="Brand" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">Birth Date</td>
<td width="150px"><asp:TextBox ID="Gender" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">IPA</td>
<td width="150px"> <asp:TextBox ID="IPA" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Model</td>
<td width="150px"><asp:TextBox ID="Model" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">Gender</td>
<td width="150px"><asp:TextBox ID="Street" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">CPT Code</td>
<td width="150px"> <asp:TextBox ID="CPTCode" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Payment Method</td>
<td width="150px"><asp:TextBox ID="PayMethod" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">Street</td>
<td width="150px"><asp:TextBox ID="City" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">ICD9/10 Code</td>
<td width="150px"> <asp:TextBox ID="ICD9Code" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px">Out of Pocket</td>
<td width="150px"><asp:TextBox ID="PayPocketAmt" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">City</td>
<td width="150px"><asp:TextBox ID="State" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px"></td>
<td width="150px"> </td>
<td width="150px">Insurance Portion</td>
<td width="150px"><asp:TextBox ID="PayInsAmt" runat="server" Width="150px"></asp:TextBox></td>
</tr>
<tr>
<td width="150px">State</td>
<td width="150px"><asp:TextBox ID="Zip" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px">Zip</td>
<td width="150px"><asp:TextBox ID="Phone1" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px">Phone1</td>
<td width="150px"><asp:TextBox ID="Phone2" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px">Phone2</td>
<td width="150px"><asp:TextBox ID="Email" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px">Email</td>
<td width="150px"><asp:TextBox ID="TextBox13" runat="server" Width="150px"></asp:TextBox></td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
<tr>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
<td width="150px"> </td>
</tr>
</table>
</asp:Content>
