{{ Form::open(['route' => 'admin.medecinconseil.refuserententePhaSubs', 'method' => 'POST', 'onsubmit'=>'showOverlay()', 'id' => 'form_entente']) }}
{{ Form::text('numeroDemandeSubstitution', $ententeprealable->first()->numeroDemandeSubstitution, ['readonly' => 'true', 'class' => 'input-chic']) }}
{{ Form::text('nomPrescrit', $ententeprealable->first()->nomPrescrit, ['readonly' => 'true', 'class' => 'input-chic', 'style' => 'color: #3498db !important;']) }}
{{ Form::text('libellePolice', $ententeprealablePhaSubs->first()->libellePolice, ['readonly' => 'true', 'class' => 'input-chic']) }}
{{ Form::text('libelleSubstitut', $ententeprealablePhaSubs->first()->libelleSubstitut, ['readonly' => 'true', 'class' => 'input-chic input-highlight']) }}
{{ Form::text('dateSysteme', $ententeprealablePhaSubs->first()->dateSysteme, ['readonly' => 'true', 'class' => 'input-chic']) }}
{{ Form::text('prestataire', $ententeprealablePhaSubs->first()->prestataire, ['readonly' => 'true', 'class' => 'input-chic']) }}
{{ Form::text('beneficiaire', $ententeprealablePhaSubs->first()->beneficiaire.' / '.$ententeprealablePhaSubs->first()->numeroBeneficiaire, ['readonly' => 'true', 'class' => 'input-chic']) }}
@if ($codeMedicament != "MEDIC")
{{ Form::text('prixPrescription', $ententeprealablePhaSubs->first()->prixPrescription, ['readonly' => 'true', 'class' => 'input-chic', 'style' => 'text-align:right; font-weight:bold;']) }}
{{ Form::text('prixSubstitution', $ententeprealablePhaSubs->first()->prixSubstitution, ['readonly' => 'true', 'class' => 'input-chic', 'style' => 'text-align:right; font-weight:bold;']) }}
{{ Form::text('gap', $ententeprealablePhaSubs->first()->gap, ['readonly' => 'true', 'class' => 'input-chic', 'style' => 'text-align:right; font-weight:bold; color:#3498db !important;']) }}
@endif
{{ Form::text('motifReel', null, ['class' => 'input-chic', 'style' => 'border-color: rgba(231,76,60,0.5) !important;', 'id' => 'motifReel', 'placeholder' => 'Motif de Refus Assureur / Instruction particulière']) }}
{{ Form::text('motifRefusAssure', $ententeprealable->first()->motifRefusAssure, ['class' => 'input-chic', 'style' => 'border-color: rgba(231,76,60,0.5) !important;', 'id' => 'motifRefusAssure', 'placeholder' => 'Motif de Refus à communiquer à l\'assuré']) }}