@extends('layouts.main') @push('styles') @endpush @section('content')

{{ __('patients.new_patient') }}

@include('flash::message') {{ Form::open(['route' => 'patients.store','data-toggle'=>'validator']) }}
{{ Form::label('first_name',__('patients.first_name')) }} {{ Form::text('first_name','',['class' => 'form-control compulsory', 'required', 'placeholder'=>'Christian name eg Fred', 'id' => 'first_name']) }}
{{ Form::label('last_name',__('patients.last_name')) }} {{ Form::text('last_name','',['class' => 'form-control compulsory', 'required','placeholder'=>'Surname eg Asiimwe', 'id' => 'last_name']) }}
{{ Form::label('gender',__('patients.gender')) }}
{{ Form::radio('gender', 1, false, ["required"]) }} {{ __('patients.male') }}    {{ Form::radio('gender', 2, false, ["required"]) }} {{ __('patients.female') }}
{{ Form::label('national_id',__('patients.national_id')) }} {{ Form::text('national_id','',['class' => 'form-control','maxlength'=>15]) }}
{{ Form::label('date_of_birth',__('patients.date_of_birth')) }}
{{ Form::text('date_of_birth','',['class' => 'form-control compulsory','readonly','id'=>'date_of_birth', 'required']) }}
{{ Form::label('age',__('patients.years')) }} {{ Form::number('age_in_years','0',['class' => 'form-control compulsory','id'=>'age_in_years','min'=>'0','max'=>'120', 'required']) }}
{{ Form::label('age',__('patients.months')) }} {{ Form::number('age_in_months','0',['class' => 'form-control','id'=>'age_in_months','min'=>'0','max'=>'12']) }}
{{ Form::label('marital_status',__('patients.marital_status')) }}
@foreach($marital_statuses as $key=>$value) {{ Form::radio('marital_status', $key,false,[]) }} {{ $value }}    @endforeach
{{ Form::label('religion',__('patients.religion')) }} {{ Form::select('religion',$religions,'',['class' => 'form-control x']) }}
{{ Form::label('occupation',__('patients.occupation')) }} {{ Form::select('occupation',$occupations,'',['class' => 'form-control occupation', 'id' => 'occupation']) }} Add new occupation
{{ Form::label('next_of_kin',__('patients.next_of_kin')) }} {{ Form::text('next_of_kin','',['class' => 'form-control compulsory', 'required']) }}
{{ Form::label('next_of_kin_relationship',__('patients.next_of_kin_relationship')) }} {{ Form::select('next_of_kin_relationship',$relationships,'',['class' => 'form-control compulsory', 'required']) }}
{{ Form::label('next_of_kin_phone',__('patients.next_of_kin_phone')) }} {{ Form::text('next_of_kin_phone','',['class' => 'form-control compulsory', 'required','pattern' => '\d{10}', 'title'=>'Phone number must be exactly 10 digits']) }}
{{ Form::label('phone',__('patients.phone')) }} {{ Form::text('phone','',['class' => 'form-control compulsory','id' => 'phone', 'required','pattern' => '\d{10}', 'title'=>'Phone number must be exactly 10 digits' ]) }}
{{ Form::label('alternative_phone', 'Alternative Phone Number') }} {{ Form::text('alternative_phone','',['class' => 'form-control','id' => 'alternative_phone','pattern' => '\d{10}', 'title'=>'Phone number must be exactly 10 digits']) }}
{{ Form::label('phone_owner',__('patients.phone_owner')) }}
{{ Form::radio('phone_owner','self',false,['id'=>'owned']) }} {{ __('patients.self') }}    {{ Form::radio('phone_owner','other',false,['id'=>'non_owned']) }} {{ __('patients.other') }}
{{ Form::label('patient_category',__('patients.patient_category'))}} {{ Form::select('patient_category',$patient_categories,'1',['class' => 'form-control compulsory', 'required', 'data-error'=>'']) }}
{{ Form::label('company',__('patients.company_slash_employer'))}} {{ Form::select('company', $companies ,'',['class' => 'form-control', 'data-error'=>'', 'id' => 'company']) }}
{{ __('patients.add_new_company') }}
{{ Form::label('language',__('patients.preferred_language')) }} {{ Form::select('language',['vern'=>'Vernacular','eng'=>'English',],'eng',['class' => 'form-control compulsory', 'required', 'data-error'=>'Select the language']) }}
{{ Form::label('citizenship',__('patients.citizenship')) }} {{ Form::select('citizenship',['1'=>'Ugandan','0'=>'Non Ugandan'],'',['class' => 'form-control compulsory', 'required', 'data-error'=>'Select the language','id' => 'citizenship']) }}
{{ Form::label('residence','Residence') }}
{{ __('patients.add_new_residence') }}
@if (!empty($patient_registration_fields)) @foreach ($patient_registration_fields as $patient_registration_field) @if (!empty($patient_registration_field->options))
{{ Form::label($patient_registration_field->name, $patient_registration_field->name) }}
@else
{{ Form::label($patient_registration_field->name, $patient_registration_field->name) }} compulsory == 1)? 'required':'' }}>
@endif @endforeach @endif @if(is_fingerprint_enabled())
{{ Form::label('fingerprint_template',__('patients.patient_fingerprint')) }}
{{ Form::hidden('fingerprint_template', '', ['id' => 'fingerprint_template']) }}

@endif

{{ Form::button(__('patients.submit'),['type'=>'submit','class'=>'btn btn-success waves-effect waves-light m-r-10', 'id' => 'patients_submit']) }} {{ Form::button(__('patients.cancel'),['type'=>'reset','class'=>'btn btn-default waves-effect waves-light']) }}
{{ Form::close() }}
@endsection {{-- start of add other foreigner country modal --}} @push('scripts') {{-- --}} {{-- palm vein scanner --}} {{-- --}} {{-- --}} {{-- end of palm vein scanner --}} @endpush