@extends('organization.layouts.master')
@section('content')
    <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;
        }

        .card-primary {
            width: 130% !important;
        }

        li {
            color: white;
        }

    </style>
    <section class="section">
        <div class="container mt-5">
            <div class="row">
                <div class="col-md-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('organization.update.user.process', ['id' => request()->id]) }}"
                            method="POST" enctype="multipart/form-data">
                            @csrf
                            <div class="card-body">
                                <div class="text-center">
                                    <h5>Patient Application</h5>
                                </div>
                                <div class="row">
                                    <div class="form-group col-md-6">
                                        <label for="fname">First Name</label>
                                        <input id="fname" type="text" class="form-control" name="fname"
                                            value="{{ old('fname', $user->user->fname) }}" autofocus required>
                                        @if ($errors->has('fname'))
                                            <div class="text-danger">{{ $errors->first('fname') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-md-6">
                                        <label for="last_name">Last Name</label>
                                        <input id="last_name" type="text" class="form-control" name="lname"
                                            value="{{ old('lname', $user->user->lname) }}" required>
                                        @if ($errors->has('lname'))
                                            <div class="text-danger">{{ $errors->first('lname') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">

                                    <div class="form-group col-md-3">
                                        <label for="email">Email</label>
                                        <input id="email" type="email" class="form-control" name="email"
                                            value="{{ old('email', $user->user->email) }}" required>
                                        @if ($errors->has('email'))
                                            <div class="text-danger">{{ $errors->first('email') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-md-3">
                                        <label for="dob">DOB</label>
                                        <input id="dob" type="date" class="form-control" name="dob"
                                            value="{{ old('dob', $user->user->dob) }}" required>
                                        @if ($errors->has('dob'))
                                            <div class="text-danger">{{ $errors->first('dob') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-md-3">
                                        <label for="city">City</label>
                                        <input id="city" type="text" class="form-control" name="city"
                                            value="{{ old('city', $user->user->city) }}" required>
                                        @if ($errors->has('city'))
                                            <div class="text-danger">{{ $errors->first('city') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-md-3">
                                        <label for="state">State</label>
                                        <input id="state" type="text" class="form-control" name="state"
                                            value="{{ old('state', $user->user->state) }}" required>
                                        @if ($errors->has('state'))
                                            <div class="text-danger">{{ $errors->first('state') }}</div>
                                        @endif
                                    </div>
                                </div>


                                <div class="row">
                                    <div class="form-group col-md-3">
                                        <label for="phone">Phone#</label>
                                        <input id="phone" type="text" class="form-control" name="phone"
                                            value="{{ old('phone', $user->user->phone) }}" pattern="/^+91(7\d|8\d|9\d)\d{9}$/" onKeyPress="if(this.value.length==15) return false;" required>
                                        @if ($errors->has('phone'))
                                            <div class="text-danger">{{ $errors->first('phone') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-md-3">
                                        <label for="gender">Gender</label>
                                        <select name="gender" id="" class="form-control">
                                            <option value="male" {{ $user->user->gender ? 'selected' : '' }}>Male</option>
                                            <option value="female" {{ $user->user->gender ? 'selected' : '' }}>Female</option>
                                        </select>
                                        @if ($errors->has('gender'))
                                            <div class="text-danger">{{ $errors->first('gender') }}</div>
                                        @endif
                                    </div>

                                    <div class="form-group col-md-3">
                                        <label for="ethnicity">Ethnicity</label>
                                        <input id="ethnicity" type="text" class="form-control" name="ethnicity"
                                            value="{{ old('ethnicity', $user->user->ethnicity) }}">
                                        @if ($errors->has('ethnicity'))
                                            <div class="text-danger">{{ $errors->first('ethnicity') }}</div>
                                        @endif
                                    </div>
                                    <div class="form-group col-md-3">
                                        <label for="zipcode">Zip Code</label>
                                        <input id="zipcode" type="number" class="form-control" name="zipcode"
                                            value="{{ old('zipcode', $user->user->zipcode) }}" required>
                                        @if ($errors->has('zipcode'))
                                            <div class="text-danger">{{ $errors->first('zipcode') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-md-12">
                                        <label for="address1">Address 1</label>
                                        <input id="address1" type="text" class="form-control" name="address_one"
                                            value="{{ old('address_one', $user->user->address_one) }}" required>
                                        @if ($errors->has('address_one'))
                                            <div class="text-danger">{{ $errors->first('address_one') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-md-12">
                                        <label for="address2">Address 2</label>
                                        <input id="address2" type="text" class="form-control" name="address_two"
                                            value="{{ old('address_two', $user->user->address_two) }}">
                                        @if ($errors->has('address_two'))
                                            <div class="text-danger">{{ $errors->first('address_two') }}</div>
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-md-12">
                                        <h3>Documents</h3>
                                        @if ($user->documents != null)
                                            @foreach ($user->documents as $document)
                                                <a href="{{ asset('uploads/user/documents/' . $document->document) }}"><img
                                                        src="{{ asset('uploads/user/documents/' . $document->document) }}"
                                                        alt="" width="150" height="150"></a>
                                            @endforeach
                                        @endif
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="form-group col-md-12">
                                        <label class="d-block">Test Selection and Diagnosis Code
                                            Selection</label>
                                        <div class="form-check form-check-inline">
                                            <input class="form-check-input" type="checkbox" id="buccal_swab"
                                                name="buccal_swab" checked disabled>
                                            <label class="form-check-label" for="buccal_swab">Buccal Swab</label>
                                            @if ($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"
                                                {{ $user->testSelections->nasal_swab ? 'checked' : '' }} name="nasal_swab">
                                            <label class="form-check-label" for="nasal_swab">Nasal Swab</label>
                                            @if ($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"
                                                {{ $user->testSelections->saliva_swab ? 'checked' : '' }}
                                                name="saliva_swab">
                                            <label class="form-check-label" for="saliva_swab">Saliva Swab</label>
                                            @if ($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"
                                                name="nasopharyngeal_swab"
                                                {{ $user->testSelections->nasopharyngeal_swab ? 'checked' : '' }}>
                                            <label class="form-check-label" for="nasopharyngeal_swab">Nasopharyngeal
                                                Swab</label>
                                            @if ($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-md-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-md-12">
                                        <h5 class="d-block">Covid-19 DX Code</h5>
                                        <div class="form-check">
                                            <input class="form-check-input" type="checkbox" name="Z03.818" id="Z03.818"
                                                readonly>
                                            <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>
                                        </div>

                                    </div>
                                </div>
                                <div class="form-group">
                                    <button type="submit" class="btn btn-primary btn-lg btn-block">
                                        Update
                                    </button>
                                </div>

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