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sirramongabriel/page_from_source.html

Created December 13, 2017 12:58
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HTML Page from source
Raw
page_from_source.html
<!--HEAD omitted for brevity-->
<div id="content-container">
<div class="page-head">
<div id="page-title">
<h1 class="page-header text-overflow">Create&nbsp;Brett Carters&nbsp;Medication Record</h1>
<!--Searchbox-->
<div class="searchbox">
<div class="input-group custom-search-form">
<input type="text" class="form-control" placeholder="Search..">
<span class="input-group-btn">
<button class="text-muted" type="button"><i class="demo-pli-magnifi-glass"></i></button>
</span>
</div>
</div><!--END .searchbox-->
</div><!--END #page-title-->
<ol class="breadcrumb">
<li><a href="/">Home</a></li>
<li><a href="/residents">Residents</a></li>
<li><a href="/residents/25">Brett Carters Profile</a></li>
<li class="active">
<a class="active" href="/residents/25/medical_record_forms/new">Create Brett Carters Medication Record</a>
</li>
</ol>
</div><!--END .page-head-->
<div id="page-content">
<div class="row">
<ul class="pad-all col-md-12" style="margin-left: -.5%;">
<a class="btn btn-purple btn-labeled fa fa-chevron-circle-left" href="/residents/25">back</a>
</ul>
</div><!--END .row-->
<div class="panel">
<div class="panel-heading panel-colorful panel-purple">
<h3 class="panel-title text-center">
<i class="fa fa-file-text-o"></i>&nbsp;&nbsp;Brett Carters&nbsp;Medication Record
</h3><!--END .panel-title-->
</div><!--END .panel-heading .panel-colorful .panel-purple-->
<div class="panel-body">
<form role="form" class="form-horizontal" id="new_medical_record_form" action="/residents/25/medical_record_forms" accept-charset="UTF-8" method="post"><input name="utf8" type="hidden" value="&#x2713;" /><input type="hidden" name="authenticity_token" value="WhNvYhz3YaMZwHV7CjodePEDCP3lZTxS9KxbYBG5xr7Nr2mOi7f/BguurE8TevIp4V1yatEkvHC4rB0B6F7Osw==" />
<!-- <div class="row">
&nbsp;&nbsp;<div id="calendar_basic" style="width: 1000px; height: 350px;"></div>
</div> -->
<!--END .row-->
<div class="row bord-all pad-all">
<div class="col-sm-6 col-md-12">
<div class="medications">
<div class="fields">
<!--XRAY START 755 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][0][medical_record_form_id]" id="medical_record_form_medications_attributes_0_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_0_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_0_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" name="medical_record_form[medications_attributes][0][name]" id="medical_record_form_medications_attributes_0_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_0_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_0_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" name="medical_record_form[medications_attributes][0][dosage]" id="medical_record_form_medications_attributes_0_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_0_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_0_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_0_time_taken_1i" name="medical_record_form[medications_attributes][0][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_0_time_taken_2i" name="medical_record_form[medications_attributes][0][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_0_time_taken_3i" name="medical_record_form[medications_attributes][0][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_0_time_taken_4i" name="medical_record_form[medications_attributes][0][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_0_time_taken_5i" name="medical_record_form[medications_attributes][0][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_0_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_0_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][0][usage_type]" id="medical_record_form_medications_attributes_0_usage_type"><option value="Scheduled">Scheduled</option>
<option value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][0][_destroy]" id="medical_record_form_medications_attributes_0__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields dynamic" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 755-->
</div><div class="fields">
<!--XRAY START 756 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][1][medical_record_form_id]" id="medical_record_form_medications_attributes_1_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_1_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_1_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="Chlorthalidone" name="medical_record_form[medications_attributes][1][name]" id="medical_record_form_medications_attributes_1_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_1_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_1_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="35mg" name="medical_record_form[medications_attributes][1][dosage]" id="medical_record_form_medications_attributes_1_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_1_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_1_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_1_time_taken_1i" name="medical_record_form[medications_attributes][1][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_1_time_taken_2i" name="medical_record_form[medications_attributes][1][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_1_time_taken_3i" name="medical_record_form[medications_attributes][1][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_1_time_taken_4i" name="medical_record_form[medications_attributes][1][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_1_time_taken_5i" name="medical_record_form[medications_attributes][1][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_1_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_1_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][1][usage_type]" id="medical_record_form_medications_attributes_1_usage_type"><option value="Scheduled">Scheduled</option>
<option selected="selected" value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][1][_destroy]" id="medical_record_form_medications_attributes_1__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields existing" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 756-->
<input type="hidden" value="241" name="medical_record_form[medications_attributes][1][id]" id="medical_record_form_medications_attributes_1_id" /></div><div class="fields">
<!--XRAY START 757 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][2][medical_record_form_id]" id="medical_record_form_medications_attributes_2_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_2_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_2_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="Aspirin" name="medical_record_form[medications_attributes][2][name]" id="medical_record_form_medications_attributes_2_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_2_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_2_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="80mg" name="medical_record_form[medications_attributes][2][dosage]" id="medical_record_form_medications_attributes_2_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_2_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_2_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_2_time_taken_1i" name="medical_record_form[medications_attributes][2][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_2_time_taken_2i" name="medical_record_form[medications_attributes][2][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_2_time_taken_3i" name="medical_record_form[medications_attributes][2][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_2_time_taken_4i" name="medical_record_form[medications_attributes][2][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_2_time_taken_5i" name="medical_record_form[medications_attributes][2][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_2_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_2_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][2][usage_type]" id="medical_record_form_medications_attributes_2_usage_type"><option selected="selected" value="Scheduled">Scheduled</option>
<option value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][2][_destroy]" id="medical_record_form_medications_attributes_2__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields existing" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 757-->
<input type="hidden" value="242" name="medical_record_form[medications_attributes][2][id]" id="medical_record_form_medications_attributes_2_id" /></div><div class="fields">
<!--XRAY START 758 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][3][medical_record_form_id]" id="medical_record_form_medications_attributes_3_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_3_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_3_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="Palamadone" name="medical_record_form[medications_attributes][3][name]" id="medical_record_form_medications_attributes_3_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_3_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_3_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="75mg" name="medical_record_form[medications_attributes][3][dosage]" id="medical_record_form_medications_attributes_3_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_3_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_3_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_3_time_taken_1i" name="medical_record_form[medications_attributes][3][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_3_time_taken_2i" name="medical_record_form[medications_attributes][3][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_3_time_taken_3i" name="medical_record_form[medications_attributes][3][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_3_time_taken_4i" name="medical_record_form[medications_attributes][3][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_3_time_taken_5i" name="medical_record_form[medications_attributes][3][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_3_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_3_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][3][usage_type]" id="medical_record_form_medications_attributes_3_usage_type"><option selected="selected" value="Scheduled">Scheduled</option>
<option value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][3][_destroy]" id="medical_record_form_medications_attributes_3__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields existing" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 758-->
<input type="hidden" value="246" name="medical_record_form[medications_attributes][3][id]" id="medical_record_form_medications_attributes_3_id" /></div><div class="fields">
<!--XRAY START 759 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][4][medical_record_form_id]" id="medical_record_form_medications_attributes_4_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_4_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_4_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="Tramadal" name="medical_record_form[medications_attributes][4][name]" id="medical_record_form_medications_attributes_4_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_4_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_4_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="75mg" name="medical_record_form[medications_attributes][4][dosage]" id="medical_record_form_medications_attributes_4_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_4_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_4_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_4_time_taken_1i" name="medical_record_form[medications_attributes][4][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_4_time_taken_2i" name="medical_record_form[medications_attributes][4][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_4_time_taken_3i" name="medical_record_form[medications_attributes][4][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_4_time_taken_4i" name="medical_record_form[medications_attributes][4][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_4_time_taken_5i" name="medical_record_form[medications_attributes][4][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_4_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_4_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][4][usage_type]" id="medical_record_form_medications_attributes_4_usage_type"><option selected="selected" value="Scheduled">Scheduled</option>
<option value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][4][_destroy]" id="medical_record_form_medications_attributes_4__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields existing" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 759-->
<input type="hidden" value="247" name="medical_record_form[medications_attributes][4][id]" id="medical_record_form_medications_attributes_4_id" /></div><div class="fields">
<!--XRAY START 760 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][5][medical_record_form_id]" id="medical_record_form_medications_attributes_5_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_5_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_5_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="Atenalol" name="medical_record_form[medications_attributes][5][name]" id="medical_record_form_medications_attributes_5_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_5_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_5_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="75mg" name="medical_record_form[medications_attributes][5][dosage]" id="medical_record_form_medications_attributes_5_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_5_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_5_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_5_time_taken_1i" name="medical_record_form[medications_attributes][5][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_5_time_taken_2i" name="medical_record_form[medications_attributes][5][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_5_time_taken_3i" name="medical_record_form[medications_attributes][5][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_5_time_taken_4i" name="medical_record_form[medications_attributes][5][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_5_time_taken_5i" name="medical_record_form[medications_attributes][5][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_5_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_5_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][5][usage_type]" id="medical_record_form_medications_attributes_5_usage_type"><option value="Scheduled">Scheduled</option>
<option selected="selected" value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][5][_destroy]" id="medical_record_form_medications_attributes_5__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields existing" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 760-->
<input type="hidden" value="248" name="medical_record_form[medications_attributes][5][id]" id="medical_record_form_medications_attributes_5_id" /></div><div class="fields">
<!--XRAY START 761 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb-->
<div class="nested-fields">
<input type="hidden" name="medical_record_form[medications_attributes][6][medical_record_form_id]" id="medical_record_form_medications_attributes_6_medical_record_form_id" />
<div class="row">
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_6_name"><span class='text text-semibold'>Medication name:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_6_name">Name</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="Methodone" name="medical_record_form[medications_attributes][6][name]" id="medical_record_form_medications_attributes_6_name" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_6_dosage"><span class='text text-semibold'>Dosage:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_6_dosage">Dosage</label><div class="col-sm-10"><input class="form-control form-control" type="text" value="1g" name="medical_record_form[medications_attributes][6][dosage]" id="medical_record_form_medications_attributes_6_dosage" /></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_6_time_taken"><span class='text text-semibold'>Time taken:</span></label><br>
<div class="mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_6_time_taken">Time taken</label><div class="col-sm-10"><div class="rails-bootstrap-forms-time-select"><input type="hidden" id="medical_record_form_medications_attributes_6_time_taken_1i" name="medical_record_form[medications_attributes][6][time_taken(1i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_6_time_taken_2i" name="medical_record_form[medications_attributes][6][time_taken(2i)]" value="1" />
<input type="hidden" id="medical_record_form_medications_attributes_6_time_taken_3i" name="medical_record_form[medications_attributes][6][time_taken(3i)]" value="1" />
<select id="medical_record_form_medications_attributes_6_time_taken_4i" name="medical_record_form[medications_attributes][6][time_taken(4i)]" class="form-control mar-btm">
<option value="">Hour</option>
<option value="00">12 AM</option>
<option value="01">01 AM</option>
<option value="02">02 AM</option>
<option value="03">03 AM</option>
<option value="04">04 AM</option>
<option value="05">05 AM</option>
<option value="06">06 AM</option>
<option value="07">07 AM</option>
<option value="08">08 AM</option>
<option value="09">09 AM</option>
<option value="10">10 AM</option>
<option value="11">11 AM</option>
<option value="12">12 PM</option>
<option value="13">01 PM</option>
<option value="14">02 PM</option>
<option value="15">03 PM</option>
<option value="16">04 PM</option>
<option value="17">05 PM</option>
<option value="18">06 PM</option>
<option value="19">07 PM</option>
<option value="20">08 PM</option>
<option value="21">09 PM</option>
<option value="22">10 PM</option>
<option value="23">11 PM</option>
</select>
: <select id="medical_record_form_medications_attributes_6_time_taken_5i" name="medical_record_form[medications_attributes][6][time_taken(5i)]" class="form-control mar-btm">
<option value="">Minute</option>
<option value="00">00</option>
<option value="15">15</option>
<option value="30">30</option>
<option value="45">45</option>
</select>
</div></div></div>
</div>
</div><!--END .col-sm-6 .col-md-3-->
<div class="col-sm-6 col-md-3 pad-btm bord-all">
<label class="control-label mar-lft" for="medical_record_form_medications_attributes_6_usage_type"><span class='text text-semibold'>Medication type:</span></label><br>
<div class="mar-top mar-lft">
<div class="form-group"><label class="sr-only control-label col-sm-2" for="medical_record_form_medications_attributes_6_usage_type">Usage type</label><div class="col-sm-10"><select class="form-control" name="medical_record_form[medications_attributes][6][usage_type]" id="medical_record_form_medications_attributes_6_usage_type"><option selected="selected" value="Scheduled">Scheduled</option>
<option value="PRN">PRN</option></select></div></div>
</div><!--END .mar-top .mar-lft-->
</div><!--END .col-sm-6 .col-md-3-->
</div><!--END .row-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-all bord-all">
<input type="hidden" name="medical_record_form[medications_attributes][6][_destroy]" id="medical_record_form_medications_attributes_6__destroy" value="false" /><a class="btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields existing" href="#">remove medication</a>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
</div><!--END .nested-fields-->
<!--XRAY END 761-->
<input type="hidden" value="249" name="medical_record_form[medications_attributes][6][id]" id="medical_record_form_medications_attributes_6_id" /></div> </div>
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row .bord-all .pad-all-->
<div class="row">
<div class="col-sm-6 col-md-12 pad-top">
<div class="links">
<a class="btn btn-sm btn-primary btn-labeled btn-icon fa fa-plus add_fields" data-association-insertion-method="before" data-association-insertion-traversal="append" data-association="medication" data-associations="medications" data-association-insertion-template="&lt;div class=&quot;fields&quot;&gt;&lt;!--XRAY START 762 /Users/barracus/rails420/whizcharts/app/views/medical_record_forms/_medication_fields.html.erb--&gt;
&lt;div class=&quot;nested-fields&quot;&gt;
&lt;input type=&quot;hidden&quot; name=&quot;medical_record_form[medications_attributes][new_medications][medical_record_form_id]&quot; id=&quot;medical_record_form_medications_attributes_new_medications_medical_record_form_id&quot; /&gt;
&lt;div class=&quot;row&quot;&gt;
&lt;div class=&quot;col-sm-6 col-md-3 pad-btm bord-all&quot;&gt;
&lt;label class=&quot;control-label mar-lft&quot; for=&quot;medical_record_form_medications_attributes_new_medications_name&quot;&gt;&lt;span class=&#39;text text-semibold&#39;&gt;Medication name:&lt;/span&gt;&lt;/label&gt;&lt;br&gt;
&lt;div class=&quot;mar-lft&quot;&gt;
&lt;div class=&quot;form-group&quot;&gt;&lt;label class=&quot;sr-only control-label col-sm-2&quot; for=&quot;medical_record_form_medications_attributes_new_medications_name&quot;&gt;Name&lt;/label&gt;&lt;div class=&quot;col-sm-10&quot;&gt;&lt;input class=&quot;form-control form-control&quot; type=&quot;text&quot; name=&quot;medical_record_form[medications_attributes][new_medications][name]&quot; id=&quot;medical_record_form_medications_attributes_new_medications_name&quot; /&gt;&lt;/div&gt;&lt;/div&gt;
&lt;/div&gt;
&lt;/div&gt;&lt;!--END .col-sm-6 .col-md-3--&gt;
&lt;div class=&quot;col-sm-6 col-md-3 pad-btm bord-all&quot;&gt;
&lt;label class=&quot;control-label mar-lft&quot; for=&quot;medical_record_form_medications_attributes_new_medications_dosage&quot;&gt;&lt;span class=&#39;text text-semibold&#39;&gt;Dosage:&lt;/span&gt;&lt;/label&gt;&lt;br&gt;
&lt;div class=&quot;mar-lft&quot;&gt;
&lt;div class=&quot;form-group&quot;&gt;&lt;label class=&quot;sr-only control-label col-sm-2&quot; for=&quot;medical_record_form_medications_attributes_new_medications_dosage&quot;&gt;Dosage&lt;/label&gt;&lt;div class=&quot;col-sm-10&quot;&gt;&lt;input class=&quot;form-control form-control&quot; type=&quot;text&quot; name=&quot;medical_record_form[medications_attributes][new_medications][dosage]&quot; id=&quot;medical_record_form_medications_attributes_new_medications_dosage&quot; /&gt;&lt;/div&gt;&lt;/div&gt;
&lt;/div&gt;
&lt;/div&gt;&lt;!--END .col-sm-6 .col-md-3--&gt;
&lt;div class=&quot;col-sm-6 col-md-3 pad-btm bord-all&quot;&gt;
&lt;label class=&quot;control-label mar-lft&quot; for=&quot;medical_record_form_medications_attributes_new_medications_time_taken&quot;&gt;&lt;span class=&#39;text text-semibold&#39;&gt;Time taken:&lt;/span&gt;&lt;/label&gt;&lt;br&gt;
&lt;div class=&quot;mar-lft&quot;&gt;
&lt;div class=&quot;form-group&quot;&gt;&lt;label class=&quot;sr-only control-label col-sm-2&quot; for=&quot;medical_record_form_medications_attributes_new_medications_time_taken&quot;&gt;Time taken&lt;/label&gt;&lt;div class=&quot;col-sm-10&quot;&gt;&lt;div class=&quot;rails-bootstrap-forms-time-select&quot;&gt;&lt;input type=&quot;hidden&quot; id=&quot;medical_record_form_medications_attributes_new_medications_time_taken_1i&quot; name=&quot;medical_record_form[medications_attributes][new_medications][time_taken(1i)]&quot; value=&quot;1&quot; /&gt;
&lt;input type=&quot;hidden&quot; id=&quot;medical_record_form_medications_attributes_new_medications_time_taken_2i&quot; name=&quot;medical_record_form[medications_attributes][new_medications][time_taken(2i)]&quot; value=&quot;1&quot; /&gt;
&lt;input type=&quot;hidden&quot; id=&quot;medical_record_form_medications_attributes_new_medications_time_taken_3i&quot; name=&quot;medical_record_form[medications_attributes][new_medications][time_taken(3i)]&quot; value=&quot;1&quot; /&gt;
&lt;select id=&quot;medical_record_form_medications_attributes_new_medications_time_taken_4i&quot; name=&quot;medical_record_form[medications_attributes][new_medications][time_taken(4i)]&quot; class=&quot;form-control mar-btm&quot;&gt;
&lt;option value=&quot;&quot;&gt;Hour&lt;/option&gt;
&lt;option value=&quot;00&quot;&gt;12 AM&lt;/option&gt;
&lt;option value=&quot;01&quot;&gt;01 AM&lt;/option&gt;
&lt;option value=&quot;02&quot;&gt;02 AM&lt;/option&gt;
&lt;option value=&quot;03&quot;&gt;03 AM&lt;/option&gt;
&lt;option value=&quot;04&quot;&gt;04 AM&lt;/option&gt;
&lt;option value=&quot;05&quot;&gt;05 AM&lt;/option&gt;
&lt;option value=&quot;06&quot;&gt;06 AM&lt;/option&gt;
&lt;option value=&quot;07&quot;&gt;07 AM&lt;/option&gt;
&lt;option value=&quot;08&quot;&gt;08 AM&lt;/option&gt;
&lt;option value=&quot;09&quot;&gt;09 AM&lt;/option&gt;
&lt;option value=&quot;10&quot;&gt;10 AM&lt;/option&gt;
&lt;option value=&quot;11&quot;&gt;11 AM&lt;/option&gt;
&lt;option value=&quot;12&quot;&gt;12 PM&lt;/option&gt;
&lt;option value=&quot;13&quot;&gt;01 PM&lt;/option&gt;
&lt;option value=&quot;14&quot;&gt;02 PM&lt;/option&gt;
&lt;option value=&quot;15&quot;&gt;03 PM&lt;/option&gt;
&lt;option value=&quot;16&quot;&gt;04 PM&lt;/option&gt;
&lt;option value=&quot;17&quot;&gt;05 PM&lt;/option&gt;
&lt;option value=&quot;18&quot;&gt;06 PM&lt;/option&gt;
&lt;option value=&quot;19&quot;&gt;07 PM&lt;/option&gt;
&lt;option value=&quot;20&quot;&gt;08 PM&lt;/option&gt;
&lt;option value=&quot;21&quot;&gt;09 PM&lt;/option&gt;
&lt;option value=&quot;22&quot;&gt;10 PM&lt;/option&gt;
&lt;option value=&quot;23&quot;&gt;11 PM&lt;/option&gt;
&lt;/select&gt;
: &lt;select id=&quot;medical_record_form_medications_attributes_new_medications_time_taken_5i&quot; name=&quot;medical_record_form[medications_attributes][new_medications][time_taken(5i)]&quot; class=&quot;form-control mar-btm&quot;&gt;
&lt;option value=&quot;&quot;&gt;Minute&lt;/option&gt;
&lt;option value=&quot;00&quot;&gt;00&lt;/option&gt;
&lt;option value=&quot;15&quot;&gt;15&lt;/option&gt;
&lt;option value=&quot;30&quot;&gt;30&lt;/option&gt;
&lt;option value=&quot;45&quot;&gt;45&lt;/option&gt;
&lt;/select&gt;
&lt;/div&gt;&lt;/div&gt;&lt;/div&gt;
&lt;/div&gt;
&lt;/div&gt;&lt;!--END .col-sm-6 .col-md-3--&gt;
&lt;div class=&quot;col-sm-6 col-md-3 pad-btm bord-all&quot;&gt;
&lt;label class=&quot;control-label mar-lft&quot; for=&quot;medical_record_form_medications_attributes_new_medications_usage_type&quot;&gt;&lt;span class=&#39;text text-semibold&#39;&gt;Medication type:&lt;/span&gt;&lt;/label&gt;&lt;br&gt;
&lt;div class=&quot;mar-top mar-lft&quot;&gt;
&lt;div class=&quot;form-group&quot;&gt;&lt;label class=&quot;sr-only control-label col-sm-2&quot; for=&quot;medical_record_form_medications_attributes_new_medications_usage_type&quot;&gt;Usage type&lt;/label&gt;&lt;div class=&quot;col-sm-10&quot;&gt;&lt;select class=&quot;form-control&quot; name=&quot;medical_record_form[medications_attributes][new_medications][usage_type]&quot; id=&quot;medical_record_form_medications_attributes_new_medications_usage_type&quot;&gt;&lt;option value=&quot;Scheduled&quot;&gt;Scheduled&lt;/option&gt;
&lt;option value=&quot;PRN&quot;&gt;PRN&lt;/option&gt;&lt;/select&gt;&lt;/div&gt;&lt;/div&gt;
&lt;/div&gt;&lt;!--END .mar-top .mar-lft--&gt;
&lt;/div&gt;&lt;!--END .col-sm-6 .col-md-3--&gt;
&lt;/div&gt;&lt;!--END .row--&gt;
&lt;div class=&quot;row&quot;&gt;
&lt;div class=&quot;col-sm-6 col-md-12 pad-all bord-all&quot;&gt;
&lt;input type=&quot;hidden&quot; name=&quot;medical_record_form[medications_attributes][new_medications][_destroy]&quot; id=&quot;medical_record_form_medications_attributes_new_medications__destroy&quot; value=&quot;false&quot; /&gt;&lt;a class=&quot;btn btn-sm btn-icon btn-danger btn-labeled fa fa-minus remove_fields dynamic&quot; href=&quot;#&quot;&gt;remove medication&lt;/a&gt;
&lt;/div&gt;&lt;!--END .col-sm-6 .col-md-12--&gt;
&lt;/div&gt;&lt;!--END .row--&gt;
&lt;/div&gt;&lt;!--END .nested-fields--&gt;
&lt;!--XRAY END 762--&gt;&lt;/div&gt;" href="#">add medication</a>
</div><!--END .medications-->
</div><!--END .col-sm-6 .col-md-12-->
</div><!--END .row-->
<div class="panel-footer text-right">
<a class="btn btn-sm btn-danger" style="margin-top: 1.5%;" href="/residents/25">cancel</a>&nbsp;&nbsp;
<input type="submit" name="commit" value="Complete!" class="btn btn-lg btn-primary" id="create_medical_record_form" />
</div>
<!--END @medications.present? -->
</form><!--END bootstrap_nested_form_for ResidentMedicalRecord-->
</div><!--END .panel-body-->
</div><!--END .panel-->
</div><!--END #page-content-->
</div><!--END .content-container-->
<!-- Footer ommited for brevity-->
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