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SendInsuranceClaim.html
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SendInsuranceClaim.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<title>Send Insurance</title>
<style>
body {
margin: 0;
font-family: Arial, sans-serif;
background-color: #FFFFFF;
display: flex;
height: 100vh;
}
.sidebar {
width: 60px;
background-color: #6D9CF9;
padding: 15px;
box-shadow: 2px 0 5px rgba(0,0,0,0.1);
display: flex;
flex-direction: column;
align-items: center;
}
.sidebar .back-arrow {
width: 24px;
height: 24px;
cursor: pointer;
margin-top: 20px;
}
.sidebar .next-arrow{
width: 24px;
height: 24px;
cursor: pointer;
margin-top: 578px;
}
.main-content {
flex: 1;
display: flex;
flex-direction: column;
}
.navbar {
background-color: #fff;
padding: 15px 30px;
box-shadow: 0 3px 7px rgba(0,0,0,0.1);
}
.navbar h1 {
margin: 0;
font-size: 30px;
}
.content {
flex: 1;
padding: 40px;
display: flex;
justify-content: center;
align-items: center;
}
.form-container {
width: 100%;
max-width: 400px;
background: #fff;
padding: 50px;
border-radius: 8px;
box-shadow: 0 0 10px rgba(0,0,0,0.1);
}
.form-container label{
display: block;
font-size: 16px;
color: #585757;
margin-bottom: 5px;
margin: 7px;
}
.form-container input[type="text"] {
width: 100%;
padding: 10px;
margin-bottom: 20px;
border: 1px solid #a8a4a4;
background-color: #EDEDED;
border-radius: 4px;
}
.form-container .button-container {
display: flex;
justify-content: space-between;
}
.form-container .button-container button {
padding: 10px 20px;
border: none;
border-radius: 4px;
cursor: pointer;
}
.form-container .button-container .cancel {
background-color: #fff;
border: 1px solid #6D9CF9;
color: #6D9CF9;
}
.form-container .button-container .add {
background-color: #6D9CF9;
color: #fff;
}
.container {
width: 100%;
max-width: 800px;
margin: 50px auto;
background-color: #fff;
border-radius: 10px;
box-shadow: 0 0 10px rgba(0,0,0,0.1);
padding: 20px;
}
.header {
font-size: 1.5em;
font-weight: bold;
margin-bottom: 20px;
}
table {
width: 100%;
border-collapse: collapse;
margin-top: 20px;
}
table thead {
background-color: #f9f9f9;
}
table th, table td {
padding: 12px;
border: 1px solid #ddd;
text-align: left;
}
table th {
font-weight: bold;
}
table th:nth-child(1) {
background-color: #f5f5f5;
}
table th:nth-child(4) {
background-color: #e8f5e9;
}
table th:nth-child(6) {
background-color: #fff8e1;
}
table th:nth-child(7) {
background-color: #fff8e1;
}
table td:nth-child(1),
table td:nth-child(4),
table td:nth-child(6),
table td:nth-child(7) {
font-weight: normal;
}
.container {
width: 100%;
max-width: 600px;
margin: 50px auto;
background-color: #fff;
border-radius: 10px;
box-shadow: 0 0 10px rgba(0,0,0,0.1);
padding: 20px;
}
.header {
font-size: 1.5em;
font-weight: bold;
margin-bottom: 20px;
}
.form-group {
margin-bottom: 15px;
}
.form-group label {
display: block;
margin-bottom: 5px;
}
.form-group input,
.form-group textarea {
width: calc(100% - 20px);
padding: 10px;
border: 1px solid #ddd;
border-radius: 5px;
font-size: 1em;
}
.form-group textarea {
resize: none;
height: 100px;
}
.form-group .inline-group {
display: flex;
justify-content: space-between;
}
.form-group .inline-group input {
width: 48%;
}
.form-group .radio-group {
display: flex;
align-items: center;
}
.form-group .radio-group label {
margin-right: 10px;
}
.button-group {
display: flex;
justify-content: space-between;
}
.button-group button {
padding: 10px 20px;
border: none;
border-radius: 5px;
font-size: 1em;
cursor: pointer;
}
.button-group .cancel {
background-color: transparent;
color: #007bff;
border: 1px solid #007bff;
}
.button-group .send {
background-color: #007bff;
color: white;
}
</style>
</head>
<body>
<div class="sidebar">
<!-- <img src="back-arrow.png" alt="Back" class="back-arrow"> -->
<svg width="48" height="48" viewBox="0 0 48 48" fill="none" xmlns="http://www.w3.org/2000/svg" alt="Back" class="back-arrow">
<path d="M10 24L22 12M10 24L22 36M10 24H38" stroke="white" stroke-width="4" stroke-linecap="round" stroke-linejoin="round"/>
</svg>
<svg width="46" height="46" viewBox="0 0 46 46" fill="none" xmlns="http://www.w3.org/2000/svg" alt="Next" class="next-arrow">
<path d="M9.58333 40.25C8.52917 40.25 7.62706 39.875 6.877 39.1249C6.12694 38.3749 5.75128 37.4721 5.75 36.4167V9.58333C5.75 8.52917 6.12567 7.62706 6.877 6.877C7.62833 6.12694 8.53044 5.75128 9.58333 5.75H23V9.58333H9.58333V36.4167H23V40.25H9.58333ZM30.6667 32.5833L28.0312 29.8042L32.9187 24.9167H17.25V21.0833H32.9187L28.0312 16.1958L30.6667 13.4167L40.25 23L30.6667 32.5833Z" fill="white"/>
</svg>
</div>
<div class="main-content">
<div class="navbar">
<h1>Send Insurance Claim</h1>
</div>
<div class="container">
<div class="header">Send Insurance Claim</div>
<div class="form-group">
<label for="patientName">Patient Name</label>
<input type="text" id="patientName" name="patientName">
</div>
<div class="form-group">
<label for="publicKey">Public Key</label>
<input type="text" id="publicKey" name="publicKey">
</div>
<div class="form-group inline-group">
<div>
<label for="aadharNumber">Aadhar Number</label>
<input type="text" id="aadharNumber" name="aadharNumber">
</div>
<div>
<label for="insuranceID">Insurance ID</label>
<input type="text" id="insuranceID" name="insuranceID">
</div>
</div>
<div class="form-group">
<label>Disease Type</label>
<div class="radio-group">
<label>
<input type="radio" name="diseaseType" value="Minor"> Minor
</label>
<label>
<input type="radio" name="diseaseType" value="Major"> Major
</label>
</div>
</div>
<div class="form-group">
<label for="diseaseDescription">Disease Description</label>
<textarea id="diseaseDescription" name="diseaseDescription"></textarea>
</div>
<div class="form-group">
<label for="expenditure">Expenditure (in rupees)</label>
<input type="text" id="expenditure" name="expenditure">
</div>
<div class="button-group">
<button class="cancel">Cancel</button>
<a href="RequestSent.html"><button class="send">Send</button></a>
</div>
</div>
</body>
</html>