{{ Form::label('first_name', __('messages.user.first_name').':', ['class' => 'form-label']) }}
{{ Form::text('first_name', null, ['class' => 'form-control', 'required', 'id' => 'patientFirstName','tabindex' => '1','placeholder'=>__('messages.user.first_name')]) }}
{{ Form::label('last_name', __('messages.user.last_name').':', ['class' => 'form-label']) }}
{{ Form::text('last_name', null, ['class' => 'form-control', 'required', 'tabindex' => '2','placeholder'=>__('messages.user.last_name')]) }}
{{ Form::label('email', __('messages.user.email').':', ['class' => 'form-label']) }}
{{ Form::text('email', null, ['class' => 'form-control','required','placeholder'=>__('messages.user.email')]) }}
{{ Form::label('dob', __('messages.user.dob').':', ['class' => 'form-label']) }}
{{ Form::text('dob', null, ['class' => (getLoggedInUser()->thememode ? 'bg-light patientBirthDate form-control' : 'bg-white patientBirthDate form-control'), 'id' => 'patientBirthDate', 'autocomplete' => 'off', 'tabindex' => '4','placeholder'=>__('messages.user.dob')]) }}
{{ Form::label('phone', __('messages.user.phone').':', ['class' => 'form-label']) }}
{{ Form::tel('phone', getCountryCode(), ['class' => 'form-control phoneNumber', 'id' => 'patientPhoneNumber', 'required', 'onkeyup' => 'if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,"")', 'tabindex' => '5']) }}
{{ Form::hidden('prefix_code',null,['class'=>'prefix_code']) }}
✓ {{__('messages.valid')}}
{{ Form::label('gender', __('messages.user.gender').':', ['class' => 'form-label']) }}
{{ Form::radio('gender', '0', true, ['class' => 'form-check-input', 'tabindex' => '6','id'=>'patientMale']) }}
{{ Form::radio('gender', '1', false, ['class' => 'form-check-input', 'tabindex' => '7','id'=>'patientFemale']) }}
{{ Form::label('blood_group', __('messages.user.blood_group').':', ['class' => 'form-label']) }}
{{ Form::select('blood_group', $bloodGroup, null, ['class' => 'form-select', 'id' => 'patientBloodGroup', 'placeholder' => __('messages.user.select_blood_group'), 'data-control' => 'select2', 'tabindex' => "9"]) }}
{{ Form::label('password', __('messages.user.password').':', ['class' => 'form-label']) }}
{{ Form::password('password', ['class' => 'form-control','required','min' => '6','max' => '10', 'tabindex' => '10','placeholder'=>__('messages.user.password')]) }}
{{ Form::label('password_confirmation', __('messages.user.password_confirmation').':', ['class' => 'form-label']) }}
{{ Form::password('password_confirmation', ['class' => 'form-control','required','min' => '6','max' => '10', 'tabindex' => '11','placeholder'=>__('messages.user.password_confirmation')]) }}
@if ($customField >= 0)
@foreach ($customField as $field)
@php
$field_values = explode(',',$field['values']);
$dateType = ($field['field_type'] == 6) ? 'customFieldDate' : 'customFieldDateTime';
$field_type = \App\Models\AddCustomFields::FIELD_TYPE_ARR[$field['field_type']];
$fieldName = 'field'.$field['id'];
@endphp
{{ Form::label($field['field_name'], $field['field_name'] . ':', ['class' => $field['is_required'] == 1 ? 'form-label dynamic-field' : 'form-label']) }}
@if ($field['is_required'] == 1)
@endif
@if ($field_type == 'date' || $field_type == 'date & Time' )
{{ Form::text($fieldName, null, ['id'=>$dateType,'class' => getLoggedInUser()->thememode || $field['is_required'] == 1 ? 'bg-light form-control dynamic-field' : 'bg-white form-control', 'autocomplete' => 'off','placeholder'=>$field['field_name'],$field['is_required'] == 1 ? 'required' : '']) }}
@elseif ($field_type == 'toggle')
@elseif ($field_type == 'select')
{{ Form::select($fieldName, $field_values, null, ['class' => $field['is_required'] == 1 ? 'form-select dynamic-field' : 'form-select', 'placeholder' => $field['field_name'], 'placeholder' => $field['field_name'], 'data-control' => 'select2',$field['is_required'] == 1 ? 'required' : '' ]) }}
@elseif ($field_type == 'multiSelect' )
{{ Form::select($fieldName.'[]', $field_values, 0, ['class' => $field['is_required'] == 1 ? 'form-select patient-multi-select dynamic-field' : 'form-select patient-multi-select', 'placeholder' => $field['field_name'], 'data-control' => 'select2','multiple' => true,$field['is_required'] == 1 ? 'required' : '']) }}
@else
{{ Form::$field_type($fieldName, null, ['class' => $field['is_required'] == 1 ? 'form-control dynamic-field' : 'form-control', 'placeholder' => $field['field_name'],$field['is_required'] == 1 ? 'required' : '','rows' => $field_type == 'textarea' ? 4 : '']) }}
@endif
@endforeach
@endif
{{ __('messages.user.address_details') }}
{{ Form::label('address1', __('messages.user.address1').':', ['class' => 'form-label']) }}
{{ Form::text('address1', null, ['class' => 'form-control','placeholder'=>__('messages.user.address1')]) }}
{{ Form::label('address2', __('messages.user.address2').':', ['class' => 'form-label']) }}
{{ Form::text('address2', null, ['class' => 'form-control','placeholder'=>__('messages.user.address2')]) }}
{{ Form::label('city', __('messages.user.city').':', ['class' => 'form-label']) }}
{{ Form::text('city', null, ['class' => 'form-control','placeholder'=>__('messages.user.city')]) }}
{{ Form::label('zip', __('messages.user.zip').':', ['class' => 'form-label']) }}
{{ Form::text('zip', null, ['class' => 'form-control', 'maxlength' => '6','minlength' => '6','placeholder'=>__('messages.user.zip')]) }}
{{ __('messages.setting.social_details') }}
{{ Form::label('facebook_url', __('messages.facebook_url').':', ['class' => 'form-label']) }}
{{ Form::text('facebook_url', null, ['class' => 'form-control patientFacebookUrl','id'=>'patientFacebookUrl', 'onkeypress' => 'return avoidSpace(event);','placeholder'=>__('messages.facebook_url')]) }}
{{ Form::label('twitter_url', __('messages.twitter_url').':', ['class' => 'form-label']) }}
{{ Form::text('twitter_url', null, ['class' => 'form-control patientTwitterUrl','id'=>'patientTwitterUrl', 'onkeypress' => 'return avoidSpace(event);','placeholder'=>__('messages.twitter_url')]) }}
{{ Form::label('instagram_url', __('messages.instagram_url').':', ['class' => 'form-label']) }}
{{ Form::text('instagram_url', null, ['class' => 'form-control patientInstagramUrl', 'id'=>'patientInstagramUrl', 'onkeypress' => 'return avoidSpace(event);','placeholder'=>__('messages.instagram_url')]) }}
{{ Form::label('linkedIn_url', __('messages.linkedIn_url').':', ['class' => 'form-label']) }}
{{ Form::text('linkedIn_url', null, ['class' => 'form-control patientLinkedInUrl','id'=>'patientLinkedInUrl', 'onkeypress' => 'return avoidSpace(event);','placeholder'=>__('messages.linkedIn_url')]) }}
{{ Form::submit(__('messages.common.save'), ['class' => 'btn btn-primary me-2','id' => 'patientSave']) }}
{!! __('messages.common.cancel') !!}