@extends('organization.layouts.master')
@section('content')
    <style>
        #upload {
            display: none;
        }

    </style>
    <style>
        .card .card-header {
            background: #fff;
        }

        h1,
        h2,
        h3,
        h4,
        h5,
        h6 {
            color: white;
        }

        label {
            color: white !important;
        }

        .card {
            background: transparent;
            box-shadow: 0px 10px 20px 0px !important;
        }

        .text-small {
            color: white;
        }

        a {
            color: #fff
        }

        /* Chrome, Safari, Edge, Opera */
        input::-webkit-outer-spin-button,
        input::-webkit-inner-spin-button {
            -webkit-appearance: none;
            margin: 0;
        }

        /* Firefox */
        input[type=number] {
            -moz-appearance: textfield;
        }

        #upload {
            display: none;
        }


        li {
            color: white;
        }

    </style>
    <section class="section">
        <div class="container mt-5">
            <div class="row">
                <div class="col-12 col-sm-10 offset-sm-1 col-md-8 offset-md-1 col-lg-8 offset-lg-1 col-xl-8 offset-xl-1">
                    <div class="card card-primary">
                        <div class="card-header">
                            <img src="{{ asset('user/assets/img/logo.png') }}" class="img-responsive mx-auto">
                        </div>
                        <form action="{{ route('client.form.process') }}" method="POST" enctype="multipart/form-data">
                            @csrf
                            <div class="card-body">
                                <div class="text-center">
                                    <h5>User Application</h5>
                                </div>
                                <div class="row">
                                    <div class="form-group col-6">
                                        <label for="fname">First Name</label>
                                        <input id="fname" type="text" class="form-control" name="fname"
                                            value="@if (old('fname') != null) {{ old('fname') }} @endif" autofocus required>
                                        @if ($errors->has('fname'))
                                            <div class="text-danger">{{ $errors->first('fname') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-6">
                                        <label for="last_name">Last Name</label>
                                        <input id="last_name" type="text" class="form-control" name="lname"
                                            value="@if (old('lname') != null) {{ old('lname') }} @endif" required>
                                        @if ($errors->has('lname'))
                                            <div class="text-danger">{{ $errors->first('lname') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="dob">DOB</label>
                                        <input id="dob" type="date" class="form-control" name="dob"
                                            value="@if (old('dob') != null) {{ old('dob') }} @endif">
                                        @if ($errors->has('dob'))
                                            <div class="text-danger">{{ $errors->first('dob') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="city">City</label>
                                        <input id="city" type="text" class="form-control" name="city"
                                            value="@if (old('city') != null) {{ old('city') }} @endif">
                                        @if ($errors->has('city'))
                                            <div class="text-danger">{{ $errors->first('city') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="state">State</label>
                                        <input id="state" type="text" class="form-control" name="state"
                                            value="@if (old('state') != null) {{ old('state') }} @endif">
                                        @if ($errors->has('state'))
                                            <div class="text-danger">{{ $errors->first('state') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="zipcode">Zip Code</label>
                                        <input id="zipcode" type="number" class="form-control" name="zipcode"
                                            value="@if (old('zipcode') != null) {{ old('zipcode') }} @endif">
                                        @if ($errors->has('zipcode'))
                                            <div class="text-danger">{{ $errors->first('zipcode') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="orgCode">Account Code</label>
                                        <input id="orgCode" type="number" class="form-control" name="orgCode"
                                            value="@if (old('orgCode') != null) {{ old('orgCode') }} @endif" min="5"
                                            onKeyPress="if(this.value.length==5) return false;" required>
                                        @if ($errors->has('orgCode'))
                                            <div class="text-danger">{{ $errors->first('orgCode') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="phone">Phone#</label>
                                        <input id="phone" type="number" class="form-control" name="phone"
                                            value="@if (old('phone') != null) {{ old('phone') }} @endif">
                                        @if ($errors->has('phone'))
                                            <div class="text-danger">{{ $errors->first('phone') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="gender">Gender</label>
                                        <select name="gender" id="" class="form-control">
                                            <option value="male">Male</option>
                                            <option value="female">Female</option>
                                        </select>
                                        @if ($errors->has('gender'))
                                            <div class="text-danger">{{ $errors->first('gender') }}</div>
                                        @endif
                                    </div>

                                    <div class="form-group col-3">
                                        <label for="ethnicity">Ethnicity</label>
                                        <input id="ethnicity" type="text" class="form-control" name="ethnicity"
                                            value="@if (old('ethnicity') != null) {{ old('ethnicity') }} @endif">
                                        @if ($errors->has('ethnicity'))
                                            <div class="text-danger">{{ $errors->first('ethnicity') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-12">
                                        <label for="address1">Address 1</label>
                                        <input id="address1" type="number" class="form-control" name="address_one"
                                            value="@if (old('address_one') != null) {{ old('address_one') }} @endif">
                                        @if ($errors->has('address_one'))
                                            <div class="text-danger">{{ $errors->first('address_one') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-12">
                                        <label for="address2">Address 2</label>
                                        <input id="address2" type="number" class="form-control" name="address_two"
                                            value="@if (old('address_two') != null) {{ old('address_two') }} @endif">
                                        @if ($errors->has('address_two'))
                                            <div class="text-danger">{{ $errors->first('address_two') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-4">
                                        <label class="d-block">Are you 18 or older?</label>
                                        <div class="form-check">
                                            <input class="form-check-input" type="radio" name="age" id="exampleRadios1"
                                                onclick="show();" value="{{ old('age') ?? 1 }}">
                                            <label class="form-check-label" for="exampleRadios1">
                                                Yes
                                            </label>
                                            @if ($errors->has('age'))
                                                <div class="text-danger">{{ $errors->first('age') }}</div>
                                            @endif
                                        </div>
                                        <div class="form-check">
                                            <input class="form-check-input" type="radio" name="age" id="exampleRadios2"
                                                onclick="show2();" value="{{ old('age') ?? 0 }}">
                                            <label class="form-check-label" for="exampleRadios2">
                                                No
                                            </label>
                                            @if ($errors->has('age'))
                                                <div class="text-danger">{{ $errors->first('age') }}</div>
                                            @endif
                                        </div>
                                    </div>

                                    <div class="form-group col-6" id="upload">
                                        <label class="d-block">Upload</label>
                                        <div class="custom-file form-control">
                                            <input type="file" class="custom-file-input" id="customFile" name="documents"
                                                multiple>
                                            <label class="custom-file-label" for="customFile">Choose file</label>
                                        </div>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-12">
                                        <label class="d-block">Test Selection and Diagnosis Code
                                            Selection</label>
                                        <div class="form-check form-check-inline">
                                            <input class="form-check-input" type="checkbox" id="buccal_swab"
                                                {{ old('buccal_swab') ? 'checked' : '' }} name="buccal_swab">
                                            <label class="form-check-label" for="buccal_swab">Buccal Swab</label>
                                            @if ($errors->has('buccal_swab'))
                                                <div class="text-danger">{{ $errors->first('buccal_swab') }}
                                                </div>
                                            @endif
                                        </div>
                                        <div class="form-check form-check-inline">
                                            <input class="form-check-input" type="checkbox" id="nasal_swab"
                                                {{ old('nasal_swab') ? 'checked' : '' }} name="nasal_swab">
                                            <label class="form-check-label" for="nasal_swab">Nasal Swab</label>
                                            @if ($errors->has('nasal_swab'))
                                                <div class="text-danger">{{ $errors->first('nasal_swab') }}
                                                </div>
                                            @endif
                                        </div>
                                        <div class="form-check form-check-inline">
                                            <input class="form-check-input" type="checkbox" id="saliva_swab"
                                                value="saliva_swab" {{ old('saliva_swab') ? 'checked' : '' }}
                                                name="saliva_swab">
                                            <label class="form-check-label" for="saliva_swab">Saliva Swab</label>
                                            @if ($errors->has('saliva_swab'))
                                                <div class="text-danger">{{ $errors->first('saliva_swab') }}
                                                </div>
                                            @endif
                                        </div>
                                        <div class="form-check form-check-inline">
                                            <input class="form-check-input" type="checkbox" id="nasopharyngeal_swab"
                                                value="Nasopharyngeal Swab" name="nasopharyngeal_swab"
                                                {{ old('nasopharyngeal_swab') ? 'checked' : '' }}>
                                            <label class="form-check-label" for="nasopharyngeal_swab">Nasopharyngeal
                                                Swab</label>
                                            @if ($errors->has('nasopharyngeal_swab'))
                                                <div class="text-danger">
                                                    {{ $errors->first('nasopharyngeal_swab') }}</div>
                                            @endif
                                        </div>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-12 text-center">
                                        <div class="form-check form-check-inline">
                                            {{-- <input class="form-check-input" type="checkbox" id="covid_19"
                                            value=""> --}}
                                            <h4 class="form-check-label" for="covid_19">COVID 19 SARS-COV-2 by
                                                RT-PCR
                                            </h4>
                                        </div>
                                    </div>
                                    <div class="form-group col-12">
                                        <h5 class="d-block">Covid-19 DX Code</h5>

                                        <div class="form-check">
                                            <input class="form-check-input" type="checkbox" id="Z03.818" name="Z03818"
                                                {{ old('Z03818') ? 'checked' : '' }}>
                                            <label class="form-check-label" for="Z03.818">
                                                Z03.818

                                            </label>
                                            <p class="form-check-label text-muted">Encounter for observation for
                                                suspected expousre to other biological agents ruled out</p>
                                            <ul>
                                                <li>For cases there is a concert for possible COVID-19 expousre</li>
                                            </ul>
                                            @if ($errors->has('Z03818'))
                                                <div class="text-danger">{{ $errors->first('Z03818') }}</div>
                                            @endif
                                        </div>
                                        <div class="form-check">
                                            <input class="form-check-input" type="checkbox" id="Z20.828" name="Z20828"
                                                {{ old('Z20828') ? 'checked' : '' }}>
                                            <label class="form-check-label" for="Z20.828">
                                                Z20.828
                                            </label>
                                            <p class="form-check-label text-muted">Contact with and (suspected)
                                                expousre to other viral communicable diseases</p>
                                            <ul>
                                                <li>Only to be used if actual expousre with someone confirmed to
                                                    have COVID-19</li>
                                            </ul>
                                            @if ($errors->has('Z20828'))
                                                <div class="text-danger">{{ $errors->first('Z20828') }}</div>
                                            @endif
                                        </div>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="barcode_id">BarCode ID</label>
                                        <input id="barcode_id" type="number" class="form-control" name="barcode_id"
                                            value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="facility">Facility</label>
                                        <input id="facility" type="text" class="form-control" name="facility" value=""
                                            required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="provider">Provider</label>
                                        <input id="provider" type="text" class="form-control" name="provider" value=""
                                            required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="npi">NPI</label>
                                        <input id="npi" type="text" class="form-control" name="npi" value="" required>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="ethnicity">Ethnicity</label>
                                        <input id="ethnicity" type="text" class="form-control" name="ethnicity" value=""
                                            required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="race">Race</label>
                                        <input id="race" type="text" class="form-control" name="race" value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="social_srcurity">Social Srcurity</label>
                                        <input id="social_srcurity" type="text" class="form-control"
                                            name="social_srcurity" value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="dl_state_id">DL/State ID</label>
                                        <input id="dl_state_id" type="number" class="form-control" name="dl_state_id"
                                            value="" required>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="date_of_collection">Date of Collection</label>
                                        <input id="date_of_collection" type="date" class="form-control"
                                            name="date_of_collection" value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="time_of_collection">Time of Collection</label>
                                        <input id="time_of_collection" type="time" class="form-control"
                                            name="time_of_collection" value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="type_of_specimen">Type of Specimen</label>
                                        <input id="type_of_specimen" type="text" class="form-control"
                                            name="type_of_specimen" value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="date_recived">Date Recived</label>
                                        <input id="date_recived" type="date" class="form-control" name="date_recived"
                                            value="" required>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="icd_10_code">ICD 10 Code</label>
                                        <input id="icd_10_code" type="text" class="form-control" name="icd_10_code"
                                            value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="insurance_type">Insurance Type</label>
                                        <input id="insurance_type" type="text" class="form-control" name="insurance_type"
                                            value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="insurer">Insurer</label>
                                        <input id="insurer" type="text" class="form-control" name="insurer" value=""
                                            required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="relation_to_insured">Relation to Insured</label>
                                        <input id="relation_to_insured" type="text" class="form-control"
                                            name="relation_to_insured" value="" required>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-3">
                                        <label for="policy_id">Policy ID</label>
                                        <input id="policy_id" type="number" class="form-control" name="policy_id"
                                            value="" required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="gourp_id">Group ID</label>
                                        <input id="gourp_id" type="number" class="form-control" name="gourp_id" value=""
                                            required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="test_type">Test Type</label>
                                        <input id="test_type" type="text" class="form-control" name="test_type" value=""
                                            required>
                                    </div>
                                    <div class="form-group col-3">
                                        <label for="test_option">Test Option</label>
                                        <input id="test_option" type="text" class="form-control" name="test_option"
                                            value="" required>
                                    </div>
                                </div>
                                <div class="form-group">
                                    <div class="custom-control custom-checkbox">
                                        <input type="checkbox" name="terms" class="custom-control-input" id="agree"
                                            {{ old('terms') ? 'checked' : '' }} required>
                                        <label class="custom-control-label" for="agree">I agree with the terms and
                                            conditions</label>
                                        @if ($errors->has('terms'))
                                            <div class="text-danger">{{ $errors->first('terms') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="form-group">
                                    <button type="submit" class="btn btn-primary btn-lg btn-block">
                                        Register
                                    </button>
                                </div>

                            </div>
                        </form>
                    </div>
                </div>
            </div>
        </div>
    </section>
@endsection