
         <div class="row form-group">
            <div class="col-md-2">
                {!! html()->label('Numéro','numero') !!}
                {!! html()->text('numero', null)->placeholder('Numéro')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
            </div>

            <div class="col-md-4">
                {!! html()->label('sonum','Employeur') !!}
                {!! html()->text('sonum', null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
            </div>
        </div>

        <div class="row form-group">
            <div class="col-md-4">
                {!! html()->label('Date d\'envoi','date_envoi') !!}
                <div class="input-group">
                    <div class='input-group date' id='datepicker_date_envoi'>
                        {!! html()->text('date_envoi', date('j/m/Y'))->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                        <span class='input-group-addon'><span class='glyphicon glyphicon-calendar'></span></span>
                    </div>
                </div>
            </div>

            <div class='col-md-4'>
                {!! html()->label('Motif','motif') !!}
                {!! html()->text('motif', $med->MotifLibelle)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
            </div>

            <div class="col-md-3">
                {!! html()->label('Mois&nbsp;manquants','nbmois') !!}
                {!! html()->text('nbmois', null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
            </div>
        </div>

        <div class='row form-group callout callout-danger'>
            <legend class="h4">Période</legend>
            <div class="col-md-4">
                {!! html()->label('Début','periode_deb') !!}
                <div class="input-group">
                    <div class='input-group date' id='datepicker_periode_debut'>
                        {!! html()->text('periode_deb', null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                        <span class='input-group-addon'><span class='glyphicon glyphicon-calendar'></span></span>
                    </div>
                </div>
            </div>

            <div class="col-md-4">
                {!! html()->label('Fin','periode_fin') !!}
                <div class="input-group">
                    <div class='input-group date' id='datepicker_periode_fin'>
                        {!! html()->text('periode_fin', null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                        <span class='input-group-addon'><span class='glyphicon glyphicon-calendar'></span></span>
                    </div>
                </div>
            </div>
        </div>


        <div class='callout callout-warning'>
            <div class='row form-group'>
                <div class="col-md-3">
                    {!! html()->label('Costisations','cotisations') !!}
                    {!! html()->text('cotisations', null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                </div>
                <div class="col-md-3">
                    {!! html()->label('Majorations','majorations') !!}
                    {!! html()->text('majorations', null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control']) !!}
                </div>
            </div>

            <div class='row form-group'>
                <div class="col-md-3">
                    {!! html()->label('Total de la dette','total') !!}
                </div>
                <div class="col-md-3" >
                    {!! html()->text('total', isset($med)?$med->majorations+$med->cotisations:null)->placeholder('')->attributes([($mode=="show"?'disabled':''),'class' => 'text-danger form-control']) !!}
                </div>
            </div>
        </div>


        <div class='form-group'>
            <div class="col-md-12">
                {!! html()->label('Observations','obs') !!}
                {!! html()->textarea('obs', null)->placeholder('Observations')->attributes([($mode=="show"?'disabled':''),'class' => 'form-control', 'rows'=>'3']) !!}
            </div>
        </div>

@if($mode=="show")
<div class="col-sm-9">
    <div class='form-group'>
        <a href="{!! url('med_print/').'/'.$med->id !!}" class="btn btn-info pull-left" style="margin-right: 3px;" target="_blank">
            <span class="glyphicon glyphicon-print">Imprimer</span>
        </a>
    </div>
 </div>
 @endif