#Montana#

<div id="modal-update" class="modal-demo">
			    <button type="button" class="close" onclick="ClosePopup();">
			        <span>&times;</span><span class="sr-only">Cerrar</span>
			    </button>
			    <h4 class="custom-modal-title">Editar Registro</h4>
			    <div class="custom-modal-text text-left">
			        <form id="form-mod-registro" role="form" method="post" action="json-registroscovac-mod.php" class="form-horizontal resize-image" enctype="multipart/form-data">
			        	<input type="hidden" id="SubmittedU" name="Submitted" value="1" />
                        <input type="hidden" id="EliminarImagen" name="EliminarImagen" value="0" />
                        <input type="hidden" id="EliminarImagen2" name="EliminarImagen2" value="0" />
                        <input type="hidden" id="EliminarImagen3" name="EliminarImagen3" value="0" />
                        <input type="hidden" id="EliminarImagen4" name="EliminarImagen4" value="0" />
                        <input type="hidden" id="EliminarImagen5" name="EliminarImagen5" value="0" />
                        <input type="hidden" id="EliminarImagen6" name="EliminarImagen6" value="0" />
			        	<input type="hidden" id="IdRegistroCovac" name="IdRegistroCovac" value="<?= $oRegistroCovac->IdRegistroCovac ?>" />

<div class="form-group">
                            <label class="col-sm-12" for="Fecha">Fecha</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control datepicker" id="FechaU" name="Fecha" placeholder="Fecha" required parsley-trigger="change" data-parsley-required-message="Por favor ingrese la fecha">
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="PacientesIngresados">Pacientes Ingresados</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" required name="PacientesIngresados" id="PacientesIngresadosU" placeholder="PacientesIngresados" required parsley-trigger="change" data-parsley-required-message="Por favor ingrese la cantidad de pacientes" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="InvestigadoresActivos">Investigadores Activos</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" required name="InvestigadoresActivos" id="InvestigadoresActivosU" placeholder="InvestigadoresActivos" required parsley-trigger="change" data-parsley-required-message="Por favor ingrese la cantidad de investigadores" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="Video">Im&aacute;gen 1</label>
                            <div class="col-sm-6 col-sm-12">
                                <div class="img-container panel-body">
                                    <div class="file-selector">
                                        <img class="img-upl" id="image-7" src="images/upload-icon.png" data-id="7" alt="Picture">
                                        <input type="file" class="img-upload" data-id="7" name="ImageSexo" id="img-7"  accept="image/*" />
                                    </div>
                                    <div class="m-t-10">
                                        <button id="btn-rm-7" type="button" class="btn btn-danger waves-effect waves-light" disabled="disabled" onclick="RemoveImage('7');"><span class="btn-label"><i class="fa fa-times"></i></span> Eliminar im&aacute;gen</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="LinkSexo">Texto 1</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" name="LinkSexo" id="LinkSexoU" placeholder="Texto 1" parsley-trigger="change" data-parsley-required-message="Por favor ingrese el link" data-parsley-type-message="Este valor debería ser un url válido" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="Video">Im&aacute;gen 2</label>
                            <div class="col-sm-6 col-sm-12">
                                <div class="img-container panel-body">
                                    <div class="file-selector">
                                        <img class="img-upl" id="image-8" src="images/upload-icon.png" data-id="8" alt="Picture">
                                        <input type="file" class="img-upload" data-id="8" name="ImageEdad" id="img-8"  accept="image/*" />
                                    </div>
                                    <div class="m-t-10">
                                        <button id="btn-rm-8" type="button" class="btn btn-danger waves-effect waves-light" disabled="disabled" onclick="RemoveImage('8');"><span class="btn-label"><i class="fa fa-times"></i></span> Eliminar im&aacute;gen</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="LinkSexo">Texto 2</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" name="LinkEdad" id="LinkEdadU" placeholder="Texto 2"  parsley-trigger="change" data-parsley-required-message="Por favor ingrese el link" data-parsley-type-message="Este valor debería ser un url válido" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="Video">Im&aacute;gen 3</label>
                            <div class="col-sm-6 col-sm-12">
                                <div class="img-container panel-body">
                                    <div class="file-selector">
                                        <img class="img-upl" id="image-9" src="images/upload-icon.png" data-id="9" alt="Picture">
                                        <input type="file" class="img-upload" data-id="9" name="ImageEnfermedadesReumaticas" id="img-9"  accept="image/*" />
                                    </div>
                                    <div class="m-t-10">
                                        <button id="btn-rm-9" type="button" class="btn btn-danger waves-effect waves-light" disabled="disabled" onclick="RemoveImage('9');"><span class="btn-label"><i class="fa fa-times"></i></span> Eliminar im&aacute;gen</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="LinkSexo">Texto 3</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" name="LinkEnfermedadesReumaticas" id="LinkEnfermedadesReumaticasU" placeholder="Texto 3" parsley-trigger="change" data-parsley-required-message="Por favor ingrese el link" data-parsley-type-message="Este valor debería ser un url válido" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="Video">Im&aacute;gen 4</label>
                            <div class="col-sm-6 col-sm-12">
                                <div class="img-container panel-body">
                                    <div class="file-selector">
                                        <img class="img-upl" id="image-10" src="images/upload-icon.png" data-id="10" alt="Picture">
                                        <input type="file" class="img-upload" data-id="10" name="ImageDistribucion" id="img-10"  accept="image/*" />
                                    </div>
                                    <div class="m-t-10">
                                        <button id="btn-rm-10" type="button" class="btn btn-danger waves-effect waves-light" disabled="disabled" onclick="RemoveImage('10');"><span class="btn-label"><i class="fa fa-times"></i></span> Eliminar im&aacute;gen</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="LinkDistribucionU">Texto 4</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" name="LinkDistribucion" id="LinkDistribucionU" placeholder="Texto 4" parsley-trigger="change" data-parsley-required-message="Por favor ingrese el link" data-parsley-type-message="Este valor debería ser un url válido" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="Video">Im&aacute;gen 5</label>
                            <div class="col-sm-6 col-sm-12">
                                <div class="img-container panel-body">
                                    <div class="file-selector">
                                        <img class="img-upl" id="image-11" src="images/upload-icon.png" data-id="1" alt="Picture">
                                        <input type="file" class="img-upload" data-id="11" name="ImagenTipoVacuna" id="img-11"  accept="image/*" />
                                    </div>
                                    <div class="m-t-10">
                                        <button id="btn-rm-11" type="button" class="btn btn-danger waves-effect waves-light" disabled="disabled" onclick="RemoveImage('11');"><span class="btn-label"><i class="fa fa-times"></i></span> Eliminar im&aacute;gen</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="LinkTipoVacunaU">Texto 5</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" name="LinkTipoVacuna" id="LinkTipoVacunaU" placeholder="Texto 5" parsley-trigger="change" data-parsley-required-message="Por favor ingrese el link" data-parsley-type-message="Este valor debería ser un url válido" />
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="Video">Im&aacute;gen 6</label>
                            <div class="col-sm-6 col-sm-12">
                                <div class="img-container panel-body">
                                    <div class="file-selector">
                                        <img class="img-upl" id="image-12" src="images/upload-icon.png" data-id="12" alt="Picture">
                                        <input type="file" class="img-upload" data-id="12" name="ImagenTipoVacuna" id="img-12"  accept="image/*" />
                                    </div>
                                    <div class="m-t-10">
                                        <button id="btn-rm-12" type="button" class="btn btn-danger waves-effect waves-light" disabled="disabled" onclick="RemoveImage('12');"><span class="btn-label"><i class="fa fa-times"></i></span> Eliminar im&aacute;gen</button>
                                    </div>
                                </div>
                            </div>
                        </div>
                        
                        <div class="form-group">
                            <label class="col-sm-12" for="LinkTipoVacunaU">Texto 6</label>
                            <div class="col-sm-12">
                                <input type="text" class="form-control" name="LinkEstadoVacunacion" id="LinkEstadoVacunacionU" placeholder="Texto 6" parsley-trigger="change" data-parsley-required-message="Por favor ingrese el link" data-parsley-type-message="Este valor debería ser un url válido" />
                            </div>
                        </div>
                        
                        <div class="text-right">
                        	<button type="submit" class="btn btn-default waves-effect waves-light">Guardar</button>
                        	<button type="button" class="btn btn-danger waves-effect waves-light m-l-10" onclick="ClosePopup();">Cancelar</button>
                    	</div>
                    </form>
			    </div>
			</div>