@extends('salesman.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 ">
                    <div class="card card-primary">
                        <div class="card-header">
                            <img src="{{ asset('user/assets/img/logo.png') }}" class="img-responsive mx-auto">
                        </div>
                        <div class="card-body">
                            <div class="text-center">
                                <h5>User Register</h5>
                            </div>

                            <div class="row">
                                <div class="form-group col-6">
                                    <label for="frist_name">First Name</label>
                                    <input id="frist_name" type="text" class="form-control" name="fname" value="" readonly
                                        required>
                                </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="" required
                                        readonly>
                                </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="" required
                                        readonly>
                                </div>
                                <div class="form-group col-3">
                                    <label for="city">City</label>
                                    <input id="city" type="text" class="form-control" name="city" value="" required
                                        readonly>
                                </div>
                                <div class="form-group col-3">
                                    <label for="state">State</label>
                                    <input id="state" type="text" class="form-control" name="state" value="" required
                                        readonly>
                                </div>
                                <div class="form-group col-3">
                                    <label for="zip_code">Zip Code</label>
                                    <input id="zip_code" type="number" class="form-control" name="zip_code" value=""
                                        readonly required>
                                </div>
                            </div>
                            <div class="row">
                                <div class="form-group col-6">
                                    <label for="phone">Phone</label>
                                    <input id="phone" type="number" class="form-control" name="phone" value="" required
                                        readonly>
                                </div>
                                <div class="form-group col-3">
                                    <label for="gender">Gender</label>
                                    <input id="gender" type="text" class="form-control" name="gender" value="" required
                                        readonly>
                                </div>

                                <div class="form-group col-3">
                                    <label for="ethnicity">Ethnicity</label>
                                    <input id="ethnicity" type="text" class="form-control" name="ethnicity" value=""
                                        readonly required>
                                </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="address1" value=""
                                        readonly required>
                                </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="address2" value=""
                                        readonly required>
                                </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="exampleRadios" readonly
                                            id="exampleRadios1" onclick="show();">
                                        <label class="form-check-label" for="exampleRadios1">
                                            Yes
                                        </label>
                                    </div>
                                    <div class="form-check">
                                        <input class="form-check-input" type="radio" name="exampleRadios" readonly
                                            id="exampleRadios2" onclick="show2();">
                                        <label class="form-check-label" for="exampleRadios2">
                                            No
                                        </label>
                                    </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" readonly>
                                        <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" value="" readonly>
                                        <label class="form-check-label" for="buccal_swab">Buccal Swab</label>
                                    </div>
                                    <div class="form-check form-check-inline">
                                        <input class="form-check-input" type="checkbox" id="nasal_swab" value="" readonly>
                                        <label class="form-check-label" for="nasal_swab">Nasal Swab</label>
                                    </div>
                                    <div class="form-check form-check-inline">
                                        <input class="form-check-input" type="checkbox" id="saliva_swab" value="" readonly>
                                        <label class="form-check-label" for="saliva_swab">Saliva Swab</label>
                                    </div>
                                    <div class="form-check form-check-inline">
                                        <input class="form-check-input" type="checkbox" id="nasopharyngeal_swab" value=""
                                            readonly>
                                        <label class="form-check-label" for="nasopharyngeal_swab">Nasopharyngeal
                                            Swab</label>
                                    </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="R05" id="R05" readonly>
                                        <label class="form-check-label" for="R05">
                                            R05
                                            <p class="text-muted">Cough</p>
                                        </label>
                                    </div>
                                    <div class="form-check">
                                        <input class="form-check-input" type="checkbox" name="R06.02" id="R06.02" readonly>
                                        <label class="form-check-label" for="R06.02">
                                            R06.02
                                        </label>
                                        <p class="form-check-label text-muted">Shortness of Breath</p>
                                    </div>
                                    <div class="form-check">
                                        <input class="form-check-input" type="checkbox" name="R50.9" id="R50.9" readonly>
                                        <label class="form-check-label" for="R50.9">
                                            R50.9
                                        </label>
                                        <p class="form-check-label text-muted">Fever, unsecified</p>
                                    </div>
                                    <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="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=""
                                        readonly required>
                                </div>
                                <div class="form-group col-3">
                                    <label for="facility">Facility</label>
                                    <input id="facility" type="text" class="form-control" name="facility" value=""
                                        readonly required>
                                </div>
                                <div class="form-group col-3">
                                    <label for="provider">Provider</label>
                                    <input id="provider" type="text" class="form-control" name="provider" value=""
                                        readonly 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
                                        readonly>
                                </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=""
                                        readonly 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
                                        readonly>
                                </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"
                                        readonly 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"
                                        readonly 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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </div>
                                <div class="form-group col-3">
                                    <label for="insurer">Insurer</label>
                                    <input id="insurer" type="text" class="form-control" name="insurer" value="" required
                                        readonly>
                                </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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </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 readonly>
                                </div>
                            </div>

                            {{-- <div class="form-group">
                                <div class="custom-control custom-checkbox">
                                    <input type="checkbox" name="terms" class="custom-control-input" id="agree" value=""
                                        required readonly>
                                    <label class="custom-control-label" for="agree">I agree with the terms and
                                        conditions</label>
                                </div>
                            </div> --}}
                            {{-- <div class="form-group">
                                <button type="submit" class="btn btn-primary btn-lg btn-block">
                                    Register
                                </button>
                            </div> --}}

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