array('patients.update', $patientData->pid), 'method' => 'PUT', 'data-abide')); ?>

First Name First Name is required and must be a string.

Middle Name Must be a string.

Last Name Last Name is required and must be a string.

DOB

Date format: yyyy-mm-dd.

Sex ( sex); ?> )

Email Invalid email format.

Phone (Home) Phone format:
(xxx)xxx-xxxx or xxx-xxx-xxxx

Phone (Cellular) Phone format:
(xxx)xxx-xxxx or xxx-xxx-xxxx

Fax Phone format:
(xxx)xxx-xxxx or xxx-xxx-xxxx

Patient Address

N/A proxy_address) && $patientExtraInfo->proxy_address == 1) echo 'checked';?> id="checkAddress" name="checkAddress" onchange="javascript:showContent();"/>

proxy_address) || $patientExtraInfo->proxy_address != 1) echo 'style="display:none;"';?> class="large-12 columns"> Proxy address proxy_address) && $patientExtraInfo->proxy_address == 1) echo 'checked';?> name="proxy_address" value="1" onchange="javascript:proxyAddress();"/>

proxy_address) || $patientExtraInfo->proxy_address != 1) echo 'style="display:none;"';?> >

Address 1 street); ?>

Address 2 streetb); ?>

City city); ?>

State state); ?>

Zipcode zip); ?>

proxy_address) && $patientExtraInfo->proxy_address == 1) echo 'style="display:none;"';?> >

Address 1 Street is required and must be a string.

Address 2 Street is required and must be a string.

City Must be a string.

State

Zipcode Zipcode is required. Five numbers

Notification Preferences

E-mail notification_preferences == 'email') echo 'checked';?> value="email" />

Fax notification_preferences == 'fax') echo 'checked';?> value="fax" />

Text notification_preferences == 'sms') echo 'checked';?> value="sms" />

Preferred Language employee_language)): ?> (Current - employee_language); ?>)

Notification and Contact Preferences

E-mail emp_notification_preferences == 'email') echo 'checked';?> value="email" />

Fax emp_notification_preferences == 'fax') echo 'checked';?> value="fax" />

Text emp_notification_preferences == 'sms') echo 'checked';?> value="sms" />

Contact Contact is required

Contact Email Contact Email is required with email format.

Contact Phone Contact Phone is required, format:
(xxx)xxx-xxxx or xxx-xxx-xxxx

Fax

Preferred Language language)): ?> (Current - language); ?>)

Employer Information

Name Employer Name is required

Address1 Street is required and must be a string.

Address2 Street is required and must be a string.