Current File : /home/inlingua/www/sensoriumpsychologists.com/diagnostics/screening/common/payments_only.php

<?php
$today_day=date("d");
$today_month=date("m");
$current_year=date("Y");
?>
        <tr id="ch_no_tr" style="display:none;">
          <td>Cheque No</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:200px;" name="cheque_no" id="cheque_no" /></td>
        </tr>
        <tr id="ch_date_tr" style="display:none;">
          <td>Cheque Date</td>
          <td align="right">:</td>
          <td>
                    <select name="doc_day" id="doc_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
          <?php
		  for($i=1;$i<=31;$i++)
		  {
			  if($i<10)
			  {
				  echo("<option value=\"0".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">0".$i."</option>");
			  }
			  else
			  {
				  echo("<option value=\"".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">".$i."</option>");
			  }
		  }
		  ?>
                    </select>
                    <select name="doc_month" id="doc_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
          <option value="01"
          <?php
		  if(abs($today_month)=="1")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jan</option>
          <option value="02"
          <?php
		  if(abs($today_month)=="2")
		  {
			  echo(" selected");
		  }
          ?>
		  >Feb</option>
          <option value="03"
          <?php
		  if(abs($today_month)=="3")
		  {
			  echo(" selected");
		  }
          ?>
		  >Mar</option>
          <option value="04"
          <?php
		  if(abs($today_month)=="4")
		  {
			  echo(" selected");
		  }
          ?>
		  >Apr</option>
          <option value="05"
          <?php
		  if(abs($today_month)=="5")
		  {
			  echo(" selected");
		  }
          ?>
		  >May</option>
          <option value="06"
          <?php
		  if(abs($today_month)=="6")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jun</option>
          <option value="07"
          <?php
		  if(abs($today_month)=="7")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jul</option>
          <option value="08"
          <?php
		  if(abs($today_month)=="8")
		  {
			  echo(" selected");
		  }
          ?>
		  >Aug</option>
          <option value="09"
          <?php
		  if(abs($today_month)=="9")
		  {
			  echo(" selected");
		  }
          ?>
		  >Sep</option>
          <option value="10"
          <?php
		  if(abs($today_month)=="10")
		  {
			  echo(" selected");
		  }
          ?>
		  >Oct</option>
          <option value="11"
          <?php
		  if(abs($today_month)=="11")
		  {
			  echo(" selected");
		  }
          ?>
		  >Nov</option>
          <option value="12"
          <?php
		  if(abs($today_month)=="12")
		  {
			  echo(" selected");
		  }
          ?>
		  >Dec</option>
                    </select>
                    <select name="doc_year" id="doc_year" class="textboxes" style="width:auto;">
<?php
echo("<option>".($current_year-1)."</option>");
echo("<option selected>".$current_year."</option>");
echo("<option>".($current_year+1)."</option>");
?>
                    </select>
                    </td>
        </tr>
        <tr id="ch_bank_tr" style="display:none;">
          <td>Cheque Bank</td>
          <td align="right">:</td>
          <td>
            <select name="cheque_bank" id="cheque_bank" style="width:auto;" class="textboxes">
              <option value="none">--- select ---</option>
<?php
$accounts_obj->view_all_banks_select();
?>           
            </select>
          </td>
        </tr>
        <tr id="ch_branch_tr" style="display:none;">
          <td>Cheque Branch</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:400px;" name="cheque_branch" id="cheque_branch" /></td>
        </tr>
        <tr id="ch_cleared_on" style="display:none;">
          <td>Cheque Cleared On</td>
          <td align="right">:</td>
          <td>
                    <select name="cleared_day" id="cleared_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
<?php
for($i=1;$i<=31;$i++)
{
	echo("<option>");
	echo($i);
	echo("</option>");
}
?>
                    </select>
                    <select name="cleared_month" id="cleared_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
                      <option value="01">Jan</option>
                      <option value="02">Feb</option>
                      <option value="03">Mar</option>
                      <option value="04">Apr</option>
                      <option value="05">May</option>
                      <option value="06">Jun</option>
                      <option value="07">Jul</option>
                      <option value="08">Aug</option>
                      <option value="09">Sep</option>
                      <option value="10">Oct</option>
                      <option value="11">Nov</option>
                      <option value="12">Dec</option>
                    </select>
                    <select name="cleared_year" id="cleared_year" class="textboxes" style="width:auto;">
                    <option value="none">-Year-</option>
<?php
$year_2=date("Y");
echo("<option>".date("Y",strtotime("-6 year"))."</option>");
echo("<option>".date("Y",strtotime("-5 year"))."</option>");
echo("<option>".date("Y",strtotime("-4 year"))."</option>");
echo("<option>".date("Y",strtotime("-3 year"))."</option>");
echo("<option>".date("Y",strtotime("-2 year"))."</option>");
echo("<option>".date("Y",strtotime("-1 year"))."</option>");
echo("<option>".$year_2."</option>");
echo("<option>".date("Y",strtotime("+1 year"))."</option>");
echo("<option>".date("Y",strtotime("+2 year"))."</option>");
echo("<option>".date("Y",strtotime("+3 year"))."</option>");
echo("<option>".date("Y",strtotime("+4 year"))."</option>");
echo("<option>".date("Y",strtotime("+5 year"))."</option>");
echo("<option>".date("Y",strtotime("+6 year"))."</option>");
?>
                    </select></td>
        </tr>
        <tr id="dd_no_tr" style="display:none;">
          <td>DD No</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:200px;" name="dd_no" id="dd_no" /></td>
        </tr>
        <tr id="dd_date_tr" style="display:none;">
          <td>DD Date</td>
          <td align="right">:</td>
          <td>
                    <select name="dd_day" id="dd_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
          <?php
		  for($i=1;$i<=31;$i++)
		  {
			  if($i<10)
			  {
				  echo("<option value=\"0".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">0".$i."</option>");
			  }
			  else
			  {
				  echo("<option value=\"".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">".$i."</option>");
			  }
		  }
		  ?>
                    </select>
                    <select name="dd_month" id="dd_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
          <option value="01"
          <?php
		  if(abs($today_month)=="1")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jan</option>
          <option value="02"
          <?php
		  if(abs($today_month)=="2")
		  {
			  echo(" selected");
		  }
          ?>
		  >Feb</option>
          <option value="03"
          <?php
		  if(abs($today_month)=="3")
		  {
			  echo(" selected");
		  }
          ?>
		  >Mar</option>
          <option value="04"
          <?php
		  if(abs($today_month)=="4")
		  {
			  echo(" selected");
		  }
          ?>
		  >Apr</option>
          <option value="05"
          <?php
		  if(abs($today_month)=="5")
		  {
			  echo(" selected");
		  }
          ?>
		  >May</option>
          <option value="06"
          <?php
		  if(abs($today_month)=="6")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jun</option>
          <option value="07"
          <?php
		  if(abs($today_month)=="7")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jul</option>
          <option value="08"
          <?php
		  if(abs($today_month)=="8")
		  {
			  echo(" selected");
		  }
          ?>
		  >Aug</option>
          <option value="09"
          <?php
		  if(abs($today_month)=="9")
		  {
			  echo(" selected");
		  }
          ?>
		  >Sep</option>
          <option value="10"
          <?php
		  if(abs($today_month)=="10")
		  {
			  echo(" selected");
		  }
          ?>
		  >Oct</option>
          <option value="11"
          <?php
		  if(abs($today_month)=="11")
		  {
			  echo(" selected");
		  }
          ?>
		  >Nov</option>
          <option value="12"
          <?php
		  if(abs($today_month)=="12")
		  {
			  echo(" selected");
		  }
          ?>
		  >Dec</option>
                    </select>
                    <select name="dd_year" id="dd_year" class="textboxes" style="width:auto;">
<?php
echo("<option>".($current_year-1)."</option>");
echo("<option selected>".$current_year."</option>");
echo("<option>".($current_year+1)."</option>");
?>
                    </select>
          </td>
        </tr>
        <tr id="dd_bank_tr" style="display:none;">
          <td>DD Bank</td>
          <td align="right">:</td>
          <td>
            <select name="dd_bank" id="dd_bank" style="width:auto;" class="textboxes">
              <option value="none">--- select ---</option>
<?php
$accounts_obj->view_all_banks_select();
?>              
            </select>
          </td>
        </tr>
        <tr id="dd_branch_tr" style="display:none;">
          <td>DD Branch</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:400px;" name="dd_branch" id="dd_branch" /></td>
        </tr>
        <tr id="dd_cleared_on" style="display:none;">
          <td>DD Cleared On</td>
          <td align="right">:</td>
          <td>
                    <select name="dd_cleared_day" id="dd_cleared_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
<?php
for($i=1;$i<=31;$i++)
{
	echo("<option>");
	echo($i);
	echo("</option>");
}
?>
                    </select>
                    <select name="dd_cleared_month" id="dd_cleared_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
                      <option value="01">Jan</option>
                      <option value="02">Feb</option>
                      <option value="03">Mar</option>
                      <option value="04">Apr</option>
                      <option value="05">May</option>
                      <option value="06">Jun</option>
                      <option value="07">Jul</option>
                      <option value="08">Aug</option>
                      <option value="09">Sep</option>
                      <option value="10">Oct</option>
                      <option value="11">Nov</option>
                      <option value="12">Dec</option>
                    </select>
                    <select name="dd_cleared_year" id="dd_cleared_year" class="textboxes" style="width:auto;">
                    <option value="none">-Year-</option>
<?php
$year_2=date("Y");
echo("<option>".date("Y",strtotime("-6 year"))."</option>");
echo("<option>".date("Y",strtotime("-5 year"))."</option>");
echo("<option>".date("Y",strtotime("-4 year"))."</option>");
echo("<option>".date("Y",strtotime("-3 year"))."</option>");
echo("<option>".date("Y",strtotime("-2 year"))."</option>");
echo("<option>".date("Y",strtotime("-1 year"))."</option>");
echo("<option>".$year_2."</option>");
echo("<option>".date("Y",strtotime("+1 year"))."</option>");
echo("<option>".date("Y",strtotime("+2 year"))."</option>");
echo("<option>".date("Y",strtotime("+3 year"))."</option>");
echo("<option>".date("Y",strtotime("+4 year"))."</option>");
echo("<option>".date("Y",strtotime("+5 year"))."</option>");
echo("<option>".date("Y",strtotime("+6 year"))."</option>");
?>
                    </select></td>
        </tr>
        <tr id="neft_no_tr" style="display:none;">
          <td>NEFT/RTGS No</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:200px;" name="neft_no" id="neft_no" /></td>
        </tr>
        <tr id="neft_date_tr" style="display:none;">
          <td>NEFT/RTGS Date</td>
          <td align="right"><span style="color:#F00;font-size:17px;font-weight:bold;">*</span>:</td>
          <td>
                    <select name="neft_day" id="neft_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
          <?php
		  for($i=1;$i<=31;$i++)
		  {
			  if($i<10)
			  {
				  echo("<option value=\"0".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">0".$i."</option>");
			  }
			  else
			  {
				  echo("<option value=\"".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">".$i."</option>");
			  }
		  }
		  ?>
                    </select>
                    <select name="neft_month" id="neft_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
          <option value="01"
          <?php
		  if(abs($today_month)=="1")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jan</option>
          <option value="02"
          <?php
		  if(abs($today_month)=="2")
		  {
			  echo(" selected");
		  }
          ?>
		  >Feb</option>
          <option value="03"
          <?php
		  if(abs($today_month)=="3")
		  {
			  echo(" selected");
		  }
          ?>
		  >Mar</option>
          <option value="04"
          <?php
		  if(abs($today_month)=="4")
		  {
			  echo(" selected");
		  }
          ?>
		  >Apr</option>
          <option value="05"
          <?php
		  if(abs($today_month)=="5")
		  {
			  echo(" selected");
		  }
          ?>
		  >May</option>
          <option value="06"
          <?php
		  if(abs($today_month)=="6")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jun</option>
          <option value="07"
          <?php
		  if(abs($today_month)=="7")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jul</option>
          <option value="08"
          <?php
		  if(abs($today_month)=="8")
		  {
			  echo(" selected");
		  }
          ?>
		  >Aug</option>
          <option value="09"
          <?php
		  if(abs($today_month)=="9")
		  {
			  echo(" selected");
		  }
          ?>
		  >Sep</option>
          <option value="10"
          <?php
		  if(abs($today_month)=="10")
		  {
			  echo(" selected");
		  }
          ?>
		  >Oct</option>
          <option value="11"
          <?php
		  if(abs($today_month)=="11")
		  {
			  echo(" selected");
		  }
          ?>
		  >Nov</option>
          <option value="12"
          <?php
		  if(abs($today_month)=="12")
		  {
			  echo(" selected");
		  }
          ?>
		  >Dec</option>
                    </select>
                    <select name="neft_year" id="neft_year" class="textboxes" style="width:auto;">
<?php
echo("<option>".($current_year-1)."</option>");
echo("<option selected>".$current_year."</option>");
echo("<option>".($current_year+1)."</option>");
?>
                    </select>
                    </td>
        </tr>
        <tr id="neft_bank_tr" style="display:none;">
          <td>NEFT/RTGS Bank</td>
          <td align="right">:</td>
          <td>
            <select name="neft_bank" id="neft_bank" style="width:auto;" class="textboxes">
              <option value="none">--- select ---</option>
<?php
$accounts_obj->view_all_banks_select();
?>              
            </select>
          </td>
        </tr>
        <tr id="neft_branch_tr" style="display:none;">
          <td>NEFT/RTGS Branch</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:400px;" name="neft_branch" id="neft_branch" /></td>
        </tr>
        <tr id="ecs_no_tr" style="display:none;">
          <td>ECS No</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:200px;" name="ecs_no" id="ecs_no" /></td>
        </tr>
        <tr id="ecs_date_tr" style="display:none;">
          <td>ECS Date</td>
          <td align="right"><span style="color:#F00;font-size:17px;font-weight:bold;">*</span>:</td>
          <td>
                    <select name="ecs_day" id="ecs_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
          <?php
		  for($i=1;$i<=31;$i++)
		  {
			  if($i<10)
			  {
				  echo("<option value=\"0".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">0".$i."</option>");
			  }
			  else
			  {
				  echo("<option value=\"".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">".$i."</option>");
			  }
		  }
		  ?>
                    </select>
                    <select name="ecs_month" id="ecs_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
          <option value="01"
          <?php
		  if(abs($today_month)=="1")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jan</option>
          <option value="02"
          <?php
		  if(abs($today_month)=="2")
		  {
			  echo(" selected");
		  }
          ?>
		  >Feb</option>
          <option value="03"
          <?php
		  if(abs($today_month)=="3")
		  {
			  echo(" selected");
		  }
          ?>
		  >Mar</option>
          <option value="04"
          <?php
		  if(abs($today_month)=="4")
		  {
			  echo(" selected");
		  }
          ?>
		  >Apr</option>
          <option value="05"
          <?php
		  if(abs($today_month)=="5")
		  {
			  echo(" selected");
		  }
          ?>
		  >May</option>
          <option value="06"
          <?php
		  if(abs($today_month)=="6")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jun</option>
          <option value="07"
          <?php
		  if(abs($today_month)=="7")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jul</option>
          <option value="08"
          <?php
		  if(abs($today_month)=="8")
		  {
			  echo(" selected");
		  }
          ?>
		  >Aug</option>
          <option value="09"
          <?php
		  if(abs($today_month)=="9")
		  {
			  echo(" selected");
		  }
          ?>
		  >Sep</option>
          <option value="10"
          <?php
		  if(abs($today_month)=="10")
		  {
			  echo(" selected");
		  }
          ?>
		  >Oct</option>
          <option value="11"
          <?php
		  if(abs($today_month)=="11")
		  {
			  echo(" selected");
		  }
          ?>
		  >Nov</option>
          <option value="12"
          <?php
		  if(abs($today_month)=="12")
		  {
			  echo(" selected");
		  }
          ?>
		  >Dec</option>
                    </select>
                    <select name="ecs_year" id="ecs_year" class="textboxes" style="width:auto;">
<?php
echo("<option>".($current_year-1)."</option>");
echo("<option selected>".$current_year."</option>");
echo("<option>".($current_year+1)."</option>");
?>
                    </select>
                    </td>
        </tr>
        <tr id="ecs_bank_tr" style="display:none;">
          <td>ECS Bank</td>
          <td align="right">:</td>
          <td>
            <select name="ecs_bank" id="ecs_bank" style="width:auto;" class="textboxes">
              <option value="none">--- select ---</option>
<?php
$accounts_obj->view_all_banks_select();
?>              
            </select>
          </td>
        </tr>
        <tr id="ecs_branch_tr" style="display:none;">
          <td>ECS Branch</td>
          <td align="right">:</td>
          <td><input type="text" class="textboxes" style="width:400px;" name="ecs_branch" id="ecs_branch" /></td>
        </tr>
        <tr id="cash_paid_on_tr" style="display:none;">
          <td>Cash paid on</td>
          <td><span style="color:#F00;font-size:17px;font-weight:bold;">*</span>:</td>
          <td>
                    <select name="cash_day" id="cash_day" class="textboxes" style="width:auto;">
                      <option value="none">-Day-</option>
          <?php
		  for($i=1;$i<=31;$i++)
		  {
			  if($i<10)
			  {
				  echo("<option value=\"0".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">0".$i."</option>");
			  }
			  else
			  {
				  echo("<option value=\"".$i."\"");
				  if(abs($today_day)==abs($i))
				  {
					  echo(" selected");
				  }
				  echo(">".$i."</option>");
			  }
		  }
		  ?>
                    </select>
                    <select name="cash_month" id="cash_month" class="textboxes" style="width:auto;">
                      <option value="none">-Month-</option>
          <option value="01"
          <?php
		  if(abs($today_month)=="1")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jan</option>
          <option value="02"
          <?php
		  if(abs($today_month)=="2")
		  {
			  echo(" selected");
		  }
          ?>
		  >Feb</option>
          <option value="03"
          <?php
		  if(abs($today_month)=="3")
		  {
			  echo(" selected");
		  }
          ?>
		  >Mar</option>
          <option value="04"
          <?php
		  if(abs($today_month)=="4")
		  {
			  echo(" selected");
		  }
          ?>
		  >Apr</option>
          <option value="05"
          <?php
		  if(abs($today_month)=="5")
		  {
			  echo(" selected");
		  }
          ?>
		  >May</option>
          <option value="06"
          <?php
		  if(abs($today_month)=="6")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jun</option>
          <option value="07"
          <?php
		  if(abs($today_month)=="7")
		  {
			  echo(" selected");
		  }
          ?>
		  >Jul</option>
          <option value="08"
          <?php
		  if(abs($today_month)=="8")
		  {
			  echo(" selected");
		  }
          ?>
		  >Aug</option>
          <option value="09"
          <?php
		  if(abs($today_month)=="9")
		  {
			  echo(" selected");
		  }
          ?>
		  >Sep</option>
          <option value="10"
          <?php
		  if(abs($today_month)=="10")
		  {
			  echo(" selected");
		  }
          ?>
		  >Oct</option>
          <option value="11"
          <?php
		  if(abs($today_month)=="11")
		  {
			  echo(" selected");
		  }
          ?>
		  >Nov</option>
          <option value="12"
          <?php
		  if(abs($today_month)=="12")
		  {
			  echo(" selected");
		  }
          ?>
		  >Dec</option>
                    </select>
                    <select name="cash_year" id="cash_year" class="textboxes" style="width:auto;">
<?php
echo("<option>".($current_year-1)."</option>");
echo("<option selected>".$current_year."</option>");
echo("<option>".($current_year+1)."</option>");
?>
                    </select>
                    </td>
        </tr>
        <tr id="cash_rpt_tr" style="display:none;">
          <td>Receipt No</td>
          <td style="text-align:right;">:</td>
          <td><input type="text" class="textboxes" style="width:400px;" name="cash_receipt_no" id="cash_receipt_no" /></td>
        </tr>