@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-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>
                    <fieldset>
                        <div class="card-body">
                            <div class="text-center">
                                <h5>Patient 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="{{$user->user->fname}}" autofocus required readonly>
                                    @if ($errors->has('fname'))
                                        <div class="text-danger">{{ $errors->first('fname') }}</div>
                                    @endif
                                </div>
                                <div class="form-group col-6">
                                    <label for="last_name">Last Name</label>
                                    <input id="last_name" type="text" class="form-control" name="lname"
                                        value="{{$user->user->lname}}" required readonly>
                                    @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="email">Email</label>
                                    <input id="email" type="email" class="form-control" name="email"
                                        value="{{ old('email', $user->user->email) }}">
                                    @if ($errors->has('email'))
                                        <div class="text-danger">{{ $errors->first('email') }}</div>
                                    @endif
                                </div>
                                <div class="form-group col-3">
                                    <label for="dob">DOB</label>
                                    <input id="dob" type="date" class="form-control" name="dob"
                                        value="{{$user->user->dob??''}}" readonly>
                                    @if ($errors->has('dob'))
                                        <div class="text-danger">{{ $errors->first('dob') }}</div>
                                    @endif
                                </div>
                                <div class="form-group col-3">
                                    <label for="city">City</label>
                                    <input id="city" type="text" class="form-control" name="city"
                                        value="{{$user->user->city??''}}" readonly>
                                    @if ($errors->has('city'))
                                        <div class="text-danger">{{ $errors->first('city') }}</div>
                                    @endif
                                </div>
                                <div class="form-group col-3">
                                    <label for="state">State</label>
                                    <input id="state" type="text" class="form-control" name="state"
                                        value="{{$user->user->state??''}}" readonly>
                                    @if ($errors->has('state'))
                                        <div class="text-danger">{{ $errors->first('state') }}</div>
                                    @endif
                                </div>
                                <div class="form-group col-3">
                                    <label for="zipcode">Zip Code</label>
                                    <input id="zipcode" type="number" class="form-control" name="zipcode"
                                        value="{{$user->user->zipcode}}" readonly>
                                    @if ($errors->has('zipcode'))
                                        <div class="text-danger">{{ $errors->first('zipcode') }}</div>
                                    @endif
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-3">
                                    <label for="phone">Phone#</label>
                                    <input id="phone" type="text" class="form-control" name="phone"
                                        value="{{$user->user->phone}}" readonly>
                                    @if ($errors->has('phone'))
                                        <div class="text-danger">{{ $errors->first('phone') }}</div>
                                    @endif
                                </div>
                                <div class="form-group col-3">
                                    <label for="gender">Gender</label>
                                    <select name="gender" id="" class="form-control" readonly>
                                        <option value="male" {{$user->user->gender?'selected':''}} readonly>Male</option>
                                        <option value="female" {{$user->user->gender?'selected':''}} readonly>Female</option>
                                    </select>
                                    @if ($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="{{$user->user->ethnicity??''}}" readonly>
                                    @if ($errors->has('ethnicity'))
                                        <div class="text-danger">{{ $errors->first('ethnicity') }}</div>
                                    @endif
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-12">
                                    <label for="address1">Address 1</label>
                                    <input id="address1" type="text" class="form-control" name="address_one"
                                        value="{{$user->user->address_one??''}}" readonly>
                                    @if ($errors->has('address_one'))
                                        <div class="text-danger">{{ $errors->first('address_one') }}</div>
                                    @endif
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-12">
                                    <label for="address2">Address 2</label>
                                    <input id="address2" type="text" class="form-control" name="address_two"
                                        value="{{$user->user->address_two??''}}" readonly>
                                    @if ($errors->has('address_two'))
                                        <div class="text-danger">{{ $errors->first('address_two') }}</div>
                                    @endif
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-12">
                                    <h3>Documents</h3>
                                    @if ($user->documents != null)
                                        @foreach ($user->documents as $document)
                                            <a href="{{asset('uploads/user/documents/'.$document->document)}}"><img src="{{asset('uploads/user/documents/'.$document->document)}}" alt="" width="150" height="150"></a>
                                        @endforeach
                                    @endif
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-12">
                                    <label class="d-block">Test Selection and Diagnosis Code
                                        Selection</label>
                                    <div class="form-check form-check-inline">
                                        <input class="form-check-input" type="checkbox" id="buccal_swab" name="buccal_swab" checked disabled>
                                        <label class="form-check-label" for="buccal_swab">Buccal Swab</label>
                                        @if ($errors->has('buccal_swab'))
                                            <div class="text-danger">{{ $errors->first('buccal_swab') }}
                                            </div>
                                        @endif
                                    </div>
                                </div>
                            </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" 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>
                    </fieldset>
                </div>
            </div>
        </div>
    </div>
</section>
@endsection






    {{-- <script>
        function show() {
            document.getElementById('upload').style.display = 'block';
        }

        function show2() {
            document.getElementById('upload').style.display = 'none';
        }
    </script> --}}