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@@ -64,7 +64,7 @@ $( function(){
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<div class="row">
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<div class="col-12">
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<div class="card">
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- <form action="./myinfo/update" id="newForm">
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+ <form action="?" id="newForm">
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<input type="hidden" value="${returnUrl}" name="returnUrl">
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<div class="card-body">
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<table class="table mobile-table">
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@@ -75,44 +75,39 @@ $( function(){
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<col style="width:35%">
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</colgroup>
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<tr>
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- <th>아이디</th>
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- <td>
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- <c:out value="${info.id}" />
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- <input type="hidden" name="id" value="${info.id}">
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- </td>
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- <th><span class="fix">*</span>이름</th>
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- <td>
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-<%-- <c:out value="${info.name}" /> --%>
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- <input type="text" class="form-control" id="name" name="name" value="${info.name}" required>
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-<%-- <input type="hidden" name="name" value="${info.name}"> --%>
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+ <th><span class="fix">*</span>신청자 명</th>
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+ <td colspan="3">
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+ <input type="text" class="form-control" placeholder="신청자 이름을 입력해주세요." required>
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</td>
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</tr>
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<tr>
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- <th><span class="fix">*</span>현재 비밀번호</th>
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+ <th>병원 명</th>
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<td colspan="3">
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- <input type="password" class="form-control" id="password" name="password" placeholder="정보수정을 위해 비밀번호를 입력해주세요." required>
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+ 테스트 병원
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</td>
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</tr>
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<tr>
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- <th>신규 비밀번호</th>
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+ <th><span class="fix">*</span>부서 명</th>
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<td colspan="3">
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- <input type="password" class="form-control" id="passwordNew" name="passwordNew" placeholder="비밀번호 변경시에만 입력해주세요.(영문, 숫자, 특수문자를 혼합하여 8 ~ 15자 이내)">
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+ <input type="text" class="form-control" placeholder="부서 명을 입력해주세요." required>
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</td>
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</tr>
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<tr>
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- <th>신규 비밀번호 확인</th>
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+ <th><span class="fix">*</span>이메일 주소</th>
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<td colspan="3">
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- <input type="password" class="form-control" id="passwordConfirm" name="passwordConfirm" placeholder="신규 비밀번호 확인을 위해 비밀번호를 한번 더 입력하세요.">
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+ <input type="text" class="form-control" placeholder="이메일 주소를 입력해주세요." required>
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</td>
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</tr>
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<tr>
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- <th>휴대폰번호</th>
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- <td>
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- <input type="text" class="form-control" value="${info.phoneNumber}" name="phoneNumber" onkeypress="onlyNumber();">
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+ <th><span class="fix">*</span>전화번호</th>
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+ <td colspan="3">
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+ <input type="text" class="form-control" placeholder="신청자 전화번호를 입력해주세요." required>
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</td>
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- <th>치료센터</th>
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- <td>
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- <c:out value="${info.centerName}" />
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+ </tr>
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+ <tr>
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+ <th><span class="fix">*</span>사용 목적</th>
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+ <td colspan="3">
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+ <textarea class="form-control" rows="10" cols="" name="content" placeholder="사용 목적을 입력해주세요" maxlength="4000" required></textarea>
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</td>
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</tr>
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</table>
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@@ -120,7 +115,7 @@ $( function(){
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<div class="col-12">
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<div class="text-right">
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<button type="button" class="btn btn-outline-primary w100" onclick="location.href='./list';">취소</button>
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- <button type="submit" class="btn btn-primary w100">수정</button>
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+ <button type="submit" class="btn btn-primary w100">서비스 신청</button>
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</div>
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</div>
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</div>
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