@extends('layouts.layout')
@section('content')
    <section class="content-header">
        <div class="container-fluid">
            <div class="row">
                <div class="col-sm-6">
                </div>
                <div class="col-sm-6">
                    <ol class="breadcrumb float-sm-right">
                        <li class="breadcrumb-item">
                            <a href="{{ route('patient-details.index') }}">@lang('Patient')</a>
                        </li>
                        <li class="breadcrumb-item active">@lang('Add Patient')</li>
                    </ol>
                </div>
            </div>
        </div>
    </section>
    <div class="row">
        <div class="col-1"></div>
        <div class="col-10">
            <div class="card shadow">
                <div class="card-header">
                    <h3 class="card-title">@lang('Add Patient')</h3>
                </div>
                <div class="card-body">
                    <form id="patientForm" class="form-material form-horizontal" action="{{ route('patient-details.store') }}" method="POST" enctype="multipart/form-data">
                        @csrf
                        <div class="row">
                            <div class="col-md-3">
                                <div class="form-group">
                                    <label for="name">@lang('Name') <b class="ambitious-crimson">*</b></label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-signature"></i></span>
                                        </div>
                                        <input type="text" id="name" name="name" value="{{ old('name') }}" class="form-control @error('name') is-invalid @enderror" placeholder="@lang('Name')" required>
                                        @error('name')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-3">
                                <div class="form-group">
                                    <label for="phone">@lang('Primary Phone (Do not add +91)') <b class="ambitious-crimson">*</b></label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-phone"></i></span>
                                        </div>
                                        <div></div>
                                        <input type="text" id="phone" name="phone" value="{{ old('phone') }}" class="form-control @error('phone') is-invalid @enderror" placeholder="@lang('This phone will use to send reminder sms (Do not add +91)')" required>
                                        {{-- <small class="form-text text-muted"></small> --}}
                                        @error('phone')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>

                            <div class="col-md-3">
                                <div class="form-group">
                                    <label for="gender">@lang('Gender')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-venus-mars"></i></span>
                                        </div>
                                        <select name="gender" class="form-control @error('gender') is-invalid @enderror" id="gender">
                                            <option value="">--@lang('Select')--</option>
                                            <option value="male" {{ old('gender') === 'male' ? 'selected' : '' }}>@lang('Male')</option>
                                            <option value="female" {{ old('gender') === 'female' ? 'selected' : '' }}>@lang('Female')</option>
                                        </select>
                                        @error('gender')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>

                            <div class="col-md-3">
                                <div class="form-group">
                                    <label for="date_of_birth">@lang('Date of Birth')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="far fa-calendar-check"></i></span>
                                        </div>
                                        <input type="text" name="date_of_birth" id="date_of_birth" class="form-control flatpickr @error('date_of_birth') is-invalid @enderror" placeholder="@lang('Date of Birth')" value="{{ old('date_of_birth') }}">
                                        @error('date_of_birth')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-12">
                                <div class="form-group">
                                    <label for="email">@lang('Primary Email') <b class="ambitious-crimson">*</b></label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-at"></i></span>
                                        </div>
                                        <input type="email" id="email" name="email" value="{{ old('email') }}" class="form-control @error('email') is-invalid @enderror" placeholder="@lang('Email')" required>
                                        <input type="button" href="javascript:void(0);" type="button" id="get_otp" value="Get Otp" class="btn btn-info">

                                        @error('email')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>

                            <div class="col-md-12" id="verifyEmailDiv" style="display: none;">
                                <div class="form-group">
                                    <label for="otp_number">@lang('Verify Email')</label>
                                    <div class="input-group mb-3">
                                        <input type="number" id="otp_number" name="otp_number" value="{{ old('otp_number') }}" class="form-control @error('otp_number') is-invalid @enderror" placeholder="@lang('Otp number')" required>
                                        <input type="button" href="javascript:void(0);" type="button" id="verify_otp" value="Verify" class="btn btn-info">
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6" hidden>
                                <div class="form-group">
                                    <label for="password">@lang('Password') <b class="ambitious-crimson">*</b></label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-key"></i></span>
                                        </div>
                                        <input type="password" id="password" name="password" value="123456789" class="form-control @error('password') is-invalid @enderror" placeholder="@lang('Password')" required>
                                        @error('password')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>

                            {{-- <div class="col-md-6">
                                <div class="form-group">
                                    <label for="add_contact">@lang('Additional Contact')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-phone"></i></span>
                                        </div>
                                        <input type="text" id="add_contact" name="add_contact" value="{{ old('add_contact') }}" class="form-control @error('add_contact') is-invalid @enderror" placeholder="@lang('Additional Contact')">
                                        @error('add_contact')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div> --}}
                        </div>

                        {{-- parent 1 --}}
                        <div class="row">
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="parent_1_name">@lang('Parent 1 Name')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-user-friends"></i></span>
                                        </div>
                                        <input type="text" id="parent_1_name" name="parent_1_name" value="{{ old('parent_1_name') }}" class="form-control @error('parent_1_name') is-invalid @enderror" placeholder="@lang('Parent 1 Name')">
                                        @error('parent_1_name')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="parent_1_phone">@lang('Parent 1 Phone')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-phone"></i></span>
                                        </div>
                                        <input type="text" id="parent_1_phone" name="parent_1_phone" value="{{ old('parent_1_phone') }}" class="form-control @error('parent_1_phone') is-invalid @enderror" placeholder="@lang('Parent 1 Phone')">
                                        <div class="input-group-append">
                                            <div class="input-group-text" data-role="hint" data-hint-text="Same as Primary Phone" data-cls-hint="bg-cyan fg-white drop-shadow">
                                                <a id="same_as_primary_phone" href="javascript:void(0)" class="btn-default"><i class="fas fa-paste"></i></a>
                                            </div>
                                        </div>
                                        @error('parent_1_phone')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="parent_1_email">@lang('Parent 1 Email')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-at"></i></span>
                                        </div>
                                        <input type="email" id="parent_1_email" name="parent_1_email" value="{{ old('parent_1_email') }}" class="form-control @error('parent_1_email') is-invalid @enderror" placeholder="@lang('Parent 1 Email')">
                                        <div class="input-group-append" data-role="hint" data-hint-text="Same as Primary Email" data-cls-hint="bg-cyan fg-white drop-shadow">
                                            <div class="input-group-text">
                                                <a id="same_as_primary_email" href="javascript:void(0)" class="btn-default"><i class="fas fa-paste"></i></a>
                                            </div>
                                        </div>
                                        @error('parent_1_email')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>

                        {{-- parent 2 --}}
                        <div class="row">
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="parent_2_name">@lang('Parent 2 Name')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-user-friends"></i></span>
                                        </div>
                                        <input type="text" id="parent_2_name" name="parent_2_name" value="{{ old('parent_2_name') }}" class="form-control @error('parent_2_name') is-invalid @enderror" placeholder="@lang('Parent 2 Name')">
                                        @error('parent_2_name')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="parent_2_phone">@lang('Parent 2 Phone')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-phone"></i></span>
                                        </div>
                                        <input type="text" id="parent_2_phone" name="parent_2_phone" value="{{ old('parent_2_phone') }}" class="form-control @error('parent_2_phone') is-invalid @enderror" placeholder="@lang('Parent 2 Phone')">

                                        @error('parent_2_phone')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-4">
                                <div class="form-group">
                                    <label for="parent_2_email">@lang('Parent 2 Email')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-at"></i></span>
                                        </div>
                                        <input type="email" id="parent_2_email" name="parent_2_email" value="{{ old('parent_2_email') }}" class="form-control @error('parent_2_email') is-invalid @enderror" placeholder="@lang('Parent 2 Email')">

                                        @error('parent_2_email')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="emergency_contact_name">@lang('Emergency Contact Name')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-user-shield"></i></span>
                                        </div>
                                        <input type="text" id="emergency_contact_name" name="emergency_contact_name" value="{{ old('emergency_contact_name') }}" class="form-control @error('emergency_contact_name') is-invalid @enderror" placeholder="@lang('Emergency Contact Name')">
                                        @error('emergency_contact_name')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="emergency_phone">@lang('Emergency Contact')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-phone"></i></span>
                                        </div>
                                        <input type="text" id="emergency_phone" name="emergency_phone" value="{{ old('emergency_phone') }}" class="form-control @error('emergency_phone') is-invalid @enderror" placeholder="@lang('Emergency Contact')">
                                        @error('emergency_phone')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            {{-- <div class="col-md-6">
                                <div class="form-group">
                                    <label for="gender">@lang('Gender')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-venus-mars"></i></span>
                                        </div>
                                        <select name="gender" class="form-control @error('gender') is-invalid @enderror" id="gender">
                                            <option value="">--@lang('Select')--</option>
                                            <option value="male" {{ old('gender') === 'male' ? 'selected' : '' }}>@lang('Male')</option>
                                            <option value="female" {{ old('gender') === 'female' ? 'selected' : '' }}>@lang('Female')</option>
                                        </select>
                                        @error('gender')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div> --}}
                            <div hidden class="col-md-6">
                                <div class="form-group">
                                    <label for="blood_group">@lang('Blood Group')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-heartbeat"></i></span>
                                        </div>
                                        <select name="blood_group" class="form-control @error('gender') is-invalid @enderror" id="blood_group">
                                            <option value="">--@lang('Select')--</option>
                                            <option selected value="A+" {{ old('blood_group') === 'A+' ? 'selected' : '' }}>A+</option>
                                            <option value="A-" {{ old('blood_group') === 'A-' ? 'selected' : '' }}>A-</option>
                                            <option value="B+" {{ old('blood_group') === 'B+' ? 'selected' : '' }}>B+</option>
                                            <option value="B-" {{ old('blood_group') === 'B-' ? 'selected' : '' }}>B-</option>
                                            <option value="O+" {{ old('blood_group') === 'O+' ? 'selected' : '' }}>O+</option>
                                            <option value="O-" {{ old('blood_group') === 'O-' ? 'selected' : '' }}>O-</option>
                                            <option value="AB+" {{ old('blood_group') === 'AB+' ? 'selected' : '' }}>AB+</option>
                                            <option value="AB-" {{ old('blood_group') === 'AB-' ? 'selected' : '' }}>AB-</option>
                                        </select>
                                        @error('blood_group')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>
                        <div class="row">
                            <div class="col-md-6">
                                <label for="photo" class="col-md-12 col-form-label">
                                    <h4>{{ __('Patient Photo') }}</h4>
                                </label>
                                <div class="col-md-12">
                                    <input id="photo" class="dropify" name="photo" value="{{ old('photo') }}" type="file" data-allowed-file-extensions="png jpg jpeg" data-max-file-size="2024K" />
                                    <p>{{ __('Max Size: 2MB, Allowed Format: png, jpg, jpeg') }}</p>
                                </div>
                                @error('photo')
                                    <div class="error ambitious-red">
                                        {{ $message }}
                                    </div>
                                @enderror
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="address">@lang('Address')</label>
                                    <div class="input-group mb-3">
                                        <textarea name="address" id="address" class="form-control @error('address') is-invalid @enderror" rows="4" placeholder="@lang('Address')">{{ old('address') }}</textarea>
                                        @error('address')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="id_card_no">@lang('ID Card Number')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-fingerprint"></i></span>
                                        </div>
                                        <input type="text" id="id_card_no" name="id_card_no" value="{{ old('id_card_no') }}" class="form-control @error('id_card_no') is-invalid @enderror" placeholder="@lang('ID Card Number')">
                                        @error('id_card_no')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>

                            <div class="col-md-6">
                                <label for="id_card_photo" class="col-md-12 col-form-label">
                                    <h4>{{ __('ID Card Upload') }}</h4>
                                </label>
                                <div class="col-md-12">
                                    <input id="id_card_photo" class="dropify" name="id_card_photo" value="{{ old('id_card_photo') }}" type="file" data-allowed-file-extensions="png jpg jpeg" data-max-file-size="2024K" />
                                    <p>{{ __('Max Size: 2MB, Allowed Format: png, jpg, jpeg') }}</p>
                                </div>
                                @error('id_card_photo')
                                    <div class="error ambitious-red">
                                        {{ $message }}
                                    </div>
                                @enderror
                            </div>
                            <div class="col-md-6" hidden>
                                <div class="form-group">
                                    <label for="id_card_no">@lang('Signature')</label>
                                    <div id="sign-pad" class="form-control" style="height: 180px;">

                                    </div>
                                    <textarea name="signature" id="signature" cols="30" rows="10" hidden></textarea>

                                </div>
                            </div>
                        </div>

                        <div class="row">
                            {{-- <div class="col-md-6">
                                <div class="form-group">
                                    <label for="date_of_birth">@lang('Date of Birth')</label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="far fa-calendar-check"></i></span>
                                        </div>
                                        <input type="text" name="date_of_birth" id="date_of_birth" class="form-control flatpickr @error('date_of_birth') is-invalid @enderror" placeholder="@lang('Date of Birth')" value="{{ old('date_of_birth') }}">
                                        @error('date_of_birth')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div> --}}
                            <div class="col-md-12">
                                <div class="form-group">
                                    <label for="status">@lang('Status') <b class="ambitious-crimson">*</b></label>
                                    <div class="input-group mb-3">
                                        <div class="input-group-prepend">
                                            <span class="input-group-text"><i class="fas fa-bell"></i></span>
                                        </div>
                                        <select class="form-control ambitious-form-loading @error('status') is-invalid @enderror" required name="status" id="status">
                                            <option value="1" {{ old('status') === '1' ? 'selected' : '' }}>@lang('Active')</option>
                                            <option value="0" {{ old('status') === '0' ? 'selected' : '' }}>@lang('Inactive')</option>
                                            <option value="2" {{ old('status') === '2' ? 'selected' : '' }}>@lang('Waitlist')</option>
                                            <option value="3" {{ old('status') === '3' ? 'selected' : '' }}>@lang('Discharged')</option>
                                        </select>
                                        @error('status')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>


                        </div>


                        <div class="row">

                        </div>


                        <div class="row">
                            <div class="col-md-12">
                                <div class="form-group">
                                    <label for="memo">@lang('Memo')</label>
                                    <div class="input-group mb-3">
                                        <textarea name="memo" id="memo" class="form-control @error('memo') is-invalid @enderror" rows="4" placeholder="@lang('Memo')">{{ old('memo') }}</textarea>
                                        @error('memo')
                                            <div class="invalid-feedback">
                                                {{ $message }}
                                            </div>
                                        @enderror
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row mb-1" hidden>
                            <div class="col-md-4">
                                <button type="button" class="btn btn-info" data-toggle="collapse" href="#caseStudy"><i class="fas fa-file-alt"></i> @lang('Medical Information')</button>
                            </div>
                            <br><br>
                        </div>
                        <div id="caseStudy" class="collapse show mb-2">
                            <div class="card-body border">
                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="weight">@lang('Weight') <b hidden class="ambitious-crimson">*</b></label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-weight"></i></span>
                                                </div>
                                                <input type="text" id="weight" name="weight" value="{{ old('weight', $patientCaseStudy->weight ?? null) }}" class="form-control" placeholder="@lang('Weight')">
                                                @error('weight')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="height">@lang('Height') <b hidden class="ambitious-crimson">*</b></label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-ruler"></i></span>
                                                </div>
                                                <input type="text" id="height" name="height" value="{{ old('height', $patientCaseStudy->height ?? null) }}" class="form-control" placeholder="@lang('Height')">
                                                @error('height')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="food_allergy">@lang('Food Allergy')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-pizza-slice"></i></span>
                                                </div>
                                                <input type="text" id="food_allergy" name="food_allergy" value="{{ old('food_allergy', $patientCaseStudy->food_allergy ?? null) }}" class="form-control @error('food_allergy') is-invalid @enderror" placeholder="@lang('Food Allergy')">
                                                @error('food_allergy')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="heart_disease">@lang('Heart Disease')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-heart-broken"></i></span>
                                                </div>
                                                <input type="text" id="heart_disease" name="heart_disease" value="{{ old('heart_disease', $patientCaseStudy->heart_disease ?? null) }}" class="form-control @error('heart_disease') is-invalid @enderror" placeholder="@lang('Heart Disease')">
                                                @error('heart_disease')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="high_blood_pressure">@lang('High Blood Pressure')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-tint"></i></span>
                                                </div>
                                                <input type="text" id="high_blood_pressure" name="high_blood_pressure" value="{{ old('high_blood_pressure', $patientCaseStudy->high_blood_pressure ?? null) }}" class="form-control @error('high_blood_pressure') is-invalid @enderror" placeholder="@lang('High Blood Pressure')">
                                                @error('high_blood_pressure')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="diabetic">@lang('Diabetic')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-drumstick-bite"></i></span>
                                                </div>
                                                <input type="text" id="diabetic" name="diabetic" value="{{ old('diabetic', $patientCaseStudy->diabetic ?? null) }}" class="form-control @error('diabetic') is-invalid @enderror" placeholder="@lang('Diabetic')">
                                                @error('diabetic')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="surgery">@lang('Surgery')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-user-nurse"></i></span>
                                                </div>
                                                <input type="text" id="surgery" name="surgery" value="{{ old('surgery', $patientCaseStudy->surgery ?? null) }}" class="form-control @error('surgery') is-invalid @enderror" placeholder="@lang('Surgery')">
                                                @error('surgery')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="accident">@lang('Accident')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-car-crash"></i></span>
                                                </div>
                                                <input type="text" id="accident" name="accident" value="{{ old('accident', $patientCaseStudy->accident ?? null) }}" class="form-control @error('accident') is-invalid @enderror" placeholder="@lang('Accident')">
                                                @error('accident')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="breastfeeding">@lang('Breast Feeding')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-baby"></i></span>
                                                </div>
                                                <input type="text" id="breastfeeding" name="breastfeeding" value="{{ old('breastfeeding', $patientCaseStudy->breastfeeding ?? null) }}" class="form-control @error('breastfeeding') is-invalid @enderror" placeholder="@lang('Breast feeding')">
                                                @error('breastfeeding')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="family_medical_history">@lang('Family Medical History')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-history"></i></span>
                                                </div>
                                                <input type="text" id="family_medical_history" name="family_medical_history" value="{{ old('family_medical_history', $patientCaseStudy->family_medical_history ?? null) }}" class="form-control @error('family_medical_history') is-invalid @enderror" placeholder="@lang('Family Medical History')">
                                                @error('family_medical_history')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="current_medication">@lang('Current Medication')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-capsules"></i></span>
                                                </div>
                                                <input type="text" id="current_medication" name="current_medication" value="{{ old('current_medication', $patientCaseStudy->current_medication ?? null) }}" class="form-control @error('current_medication') is-invalid @enderror" placeholder="@lang('Current Medication')">
                                                @error('current_medication')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="pregnancy">@lang('Pregnancy')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-female"></i></span>
                                                </div>
                                                <input type="text" id="pregnancy" name="pregnancy" value="{{ old('pregnancy', $patientCaseStudy->pregnancy ?? null) }}" class="form-control @error('pregnancy') is-invalid @enderror" placeholder="@lang('Pregnancy')">
                                                @error('pregnancy')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row" hidden>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="birth_place">@lang('Birth Place')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-city"></i></span>
                                                </div>
                                                <input type="text" id="birth_place" name="birth_place" value="{{ old('birth_place', $patientCaseStudy->birth_place ?? null) }}" class="form-control @error('birth_place') is-invalid @enderror" placeholder="@lang('Birth Place')">
                                                @error('birth_place')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-6">
                                        <div class="form-group">
                                            <label for="birth_time">@lang('Birth Time')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-clock"></i></span>
                                                </div>
                                                <input type="text" id="birth_time" name="birth_time" value="{{ old('birth_time', $patientCaseStudy->birth_time ?? null) }}" class="form-control time-flatpickr @error('birth_time') is-invalid @enderror" placeholder="@lang('Birth Time')">
                                                @error('birth_time')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row">
                                    <div class="col-md-4">
                                        <div class="form-group">
                                            <label for="referred_by">@lang('Referred By')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-user-tie"></i></span>
                                                </div>
                                                <input type="text" id="referred_by" name="referred_by" value="{{ old('referred_by', $patientCaseStudy->referred_by ?? null) }}" class="form-control @error('referred_by') is-invalid @enderror" placeholder="@lang('Refered By')">
                                                @error('referred_by')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-4">
                                        <div class="form-group">
                                            <label for="referrer_phone">@lang('Referrer Phone')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-phone"></i></span>
                                                </div>
                                                <input type="text" id="referrer_phone" name="referrer_phone" value="{{ old('referrer_phone', $patientCaseStudy->referrer_phone ?? null) }}" class="form-control @error('referrer_phone') is-invalid @enderror" placeholder="@lang('Referrer Phone')">
                                                @error('referrer_phone')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>

                                    <div class="col-md-4">
                                        <div class="form-group">
                                            <label for="referal_town">@lang('Referring Town')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fab fa-squarespace"></i></span>
                                                </div>
                                                <input type="text" id="referal_town" name="referal_town" value="{{ old('referal_town', $patientCaseStudy->referal_town ?? null) }}" class="form-control @error('referal_town') is-invalid @enderror" placeholder="@lang('Referring Town')">
                                                @error('referal_town')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row border rounded">
                                    <label class="col-md-12" for="">@lang('Referred For')</label>
                                    <div class="col-md-2">
                                        <input type="checkbox" id="ot" name="ot" {{ $patientCaseStudy->referal_for ?? ((old('ot', $patientCaseStudy->referal_for->ot == 1) ? 'checked' : '') ?? null) }} data-role="checkbox" data-style="2" data-caption="OT" data-cls-check="bd-cyan">
                                    </div>

                                    <div class="col-md-2">
                                        <input type="checkbox" id="pt" name="pt" {{ (old('pt', $patientCaseStudy->referal_for->pt == 1) ? 'checked' : '') ?? null }} data-role="checkbox" data-style="2" data-caption="PT" data-cls-check="bd-cyan">
                                    </div>

                                    <div class="col-md-2">
                                        <input type="checkbox" id="aba" name="aba" {{ (old('aba', $patientCaseStudy->referal_for->aba == 1) ? 'checked' : '') ?? null }} data-role="checkbox" data-style="2" data-caption="ABA" data-cls-check="bd-cyan">
                                    </div>

                                    <div class="col-md-2">
                                        <input type="checkbox" id="speech" name="speech" {{ (old('speech', $patientCaseStudy->referal_for->speech == 1) ? 'checked' : '') ?? null }} data-role="checkbox" data-style="2" data-caption="Speech" data-cls-check="bd-cyan">
                                    </div>

                                    <div class="col-md-4">
                                        <div class="form-group">
                                            <label for="pregnancy">@lang('Other')</label>
                                            <div class="input-group">
                                                <input type="text" id="other" name="other" class="form-control" value="{{ old('pregnancy', $patientCaseStudy->referal_for->other ?? null) }}" placeholder="other">
                                                @error('pregnancy')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>

                                <div class="row">
                                    <div class="col-md-12" hidden>
                                        <div class="form-group">
                                            <label for="others">@lang('Other Information')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fab fa-ethereum"></i></span>
                                                </div>
                                                <textarea id="others" name="others" cols="12" rows="3" class="form-control @error('others') is-invalid @enderror" placeholder="@lang('Other Information')">{{ old('others', $patientCaseStudy->others ?? null) }}</textarea>
                                                @error('others')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                    <div class="col-md-12">
                                        <div class="form-group">
                                            <label for="health_insurance">@lang('Payor')</label>
                                            <div class="input-group mb-3">
                                                <div class="input-group-prepend">
                                                    <span class="input-group-text"><i class="fas fa-briefcase-medical"></i></span>
                                                </div>
                                                <select name="health_insurance" id="health_insurance" class="form-control ambitious-form-loading @error('health_insurance') is-invalid @enderror">
                                                    <option value="cash" {{ old('health_insurance', $patientCaseStudy->health_insurance ?? null) == 'cash' ? 'selected' : '' }}>@lang('Cash')</option>
                                                    <option value="insurance" {{ old('health_insurance', $patientCaseStudy->health_insurance ?? null) == 'insurance' ? 'selected' : '' }}>@lang('Insurance')</option>
                                                    <option value="other" {{ old('health_insurance', $patientCaseStudy->health_insurance ?? null) == 'other' ? 'selected' : '' }}>@lang('Other')</option>
                                                </select>
                                                {{-- <input type="text" name="health_insurance" id="health_insurance" class="form-control @error('health_insurance') is-invalid @enderror" placeholder="@lang('Health Insurance')" value="{{ old('health_insurance', $patientCaseStudy->health_insurance ?? null) }}"> --}}
                                                @error('health_insurance')
                                                    <div class="invalid-feedback">
                                                        {{ $message }}
                                                    </div>
                                                @enderror
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                        </div>

                        <div class="row border rounded">
                            <div class="col-md-12">
                                <label class="col-md-12 col-form-label">
                                    <h4>{{ __('Reminder Settings') }}</h4>
                                </label>
                            </div>
                            <div class="col-md-4">
                                <label for="email_reminder" class="col-md-12 col-form-label">
                                    <h4>{{ __('Email Reminder') }}</h4>
                                </label>
                                <div class="input-group mb-3">
                                    <input type="checkbox" id="email_reminder" name="email_reminder" {{ old('email_reminder') ? 'checked' : '' }} data-toggle="toggle" data-size="sm" data-onstyle="info">
                                    @error('email_reminder')
                                        <div class="invalid-feedback">
                                            {{ $message }}
                                        </div>
                                    @enderror
                                </div>
                            </div>
                            <div class="col-md-4">
                                <label for="sms_reminder">@lang('SMS Reminder')</label>
                                <div class="input-group mb-3">
                                    <input type="checkbox" id="sms_reminder" name="sms_reminder" {{ old('sms_reminder') ? 'checked' : '' }} data-toggle="toggle" data-size="sm" data-onstyle="info">
                                    @error('sms_reminder')
                                        <div class="invalid-feedback">
                                            {{ $message }}
                                        </div>
                                    @enderror
                                </div>
                            </div>
                        </div>

                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label class="col-md-3 col-form-label"></label>
                                    <div class="col-md-8">
                                        <input type="submit" value="{{ __('Submit') }}" class="btn btn-outline btn-info btn-lg" />
                                        <a href="{{ route('doctor-details.index') }}" class="btn btn-outline btn-warning btn-lg">{{ __('Cancel') }}</a>
                                    </div>
                                </div>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
@endsection

@push('footer')
    <script>
        $(document).ready(function() {
            $('.time-flatpickr').flatpickr({
                noCalendar: true,
                enableTime: true,
                dateFormat: 'h:i K'
            });

            $('#same_as_primary_email').click(function() {
                $('#parent_1_email').val($('#email').val()).change();
            });

            $('#same_as_primary_phone').click(function() {
                $('#parent_1_phone').val($('#phone').val()).change();
            });



            $("#sign-pad").mouseup(function() {
                const $sigDiv = $("#sign-pad");
                const $sigInput = $("#signature");
                const dataURL = $sigDiv.jSignature("getData", "image");
                $sigInput.val(dataURL);
            });


           $("#get_otp").click(function(e) {
                e.preventDefault();
                let _url = '{{ route("email.otp.send") }}';
                $.ajax({
                    url: _url,
                    method: 'post',
                    data: {
                        email: $('#email').val()
                    },
                    cache: false,
                   

                    success: function(response) {
                        
                        Swal.fire(
                            'OTP!',
                            'Sent Successfully!',
                            'success'
                        )

                        
                        $('#verifyEmailDiv').show();
                    },
                    error: function(response) {
                        Swal.fire(
                                'Alert!',
                                response.responseJSON.message,
                                'info'
                            )                      
                    }

                });
            });

            $("#verify_otp").click(function(e) {
                e.preventDefault();
                let _url = '{{ route("email.otp.verify") }}';
                $.ajax({
                    url: _url,
                    method: 'post',
                    data: {
                        otp: $('#otp_number').val()
                    },
                    cache: false,
                    

                    success: function(response) { 
                        if(response == true){
                            Swal.fire(
                            'OTP!',
                            'Verified!',
                            'success'
                        );

                        }else{
                            Swal.fire(
                            'OTP!',
                            'Invalid!',
                            'error'
                        );

                        }
                    },
                    error: function(response) {
                        Swal.fire(
                            'Alert!',
                            response.responseJSON.message,
                            'info'
                        )                       
                    }

                });
            });


        });
    </script>
@endpush