{% extends 'base.html' %}

{% block content %}


    <div id="dgtic-ex-dialog-nuevopaciente" style="display: none">

        <form id="formulariopaciente" name="formulariopaciente" class="dgtic-form dgtic-form-inline"
              onsubmit='return false;'> {% csrf_token %}

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">RFC</label>

                <div class="dgtic-form-item large">
                    <input type="text" name="rfc" disabled id="rfc_input_popup">
                </div>
            </div>
            <br>

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">Nombre</label>

                <div class="dgtic-form-item large">
                    <input type="text" name="nombre" id="nombre_input_popup">
                </div>
            </div>
            <br>

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">Apellido Paterno</label>

                <div class="dgtic-form-item large">
                    <input type="text" name="apellido_p" id="ap_paterno_input_popup">
                </div>
            </div>
            <br>

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">Apellido Materno</label>

                <div class="dgtic-form-item large">
                    <input type="text" name="apellido_m" id="ap_materno_input_popup">
                </div>
            </div>
            <br>

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">Edad</label>

                <div class="dgtic-form-item large">
                    <input type="text" name="edad" id="edad_input_popup">
                </div>
            </div>
            <br>

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">Sexo</label>

                <div class="dgtic-form-item large">
                    <select name="sexo" id="sexo_select_popup">
                        <option>Seleccione...</option>
                        <option value='H'>Hombre</option>
                        <option value='M'>Mujer</option>
                    </select>
                </div>
            </div>
            <br>

            <div class="dgtic-form-row">
                <label class="dgtic-form-label">Derechohabiente</label>

                <div class="dgtic-form-item large">
                    <select name="derechohabiente" id="derechohabiente_select_popup">

                    </select>
                </div>
            </div>
            <br>
        </form>
    </div>

{% endblock %}

{% block extrajs %}



{% endblock%}